Systems and instruments for suction and irrigation

ABSTRACT

Provided is a robotic system that includes a surgical instrument with a wrist including an elongate shaft extending between a proximal end and a distal end, a wrist extending from the distal end of the elongate shaft, and an end effector extending from the wrist. The end effector may include a first jaw and a second jaw, the first and second jaw being moveable between an open position in which ends of the jaws are separated from each other, and a closed position in which the ends of the jaws are closer to each other as compared to the open position. The surgical instrument may also include a tube extending through the elongate shaft and the wrist, the tube having an outlet in fluid communication with a passage formed by an interior of the first and second jaws when the jaws are in the closed position.

CROSS-REFERENCE TO RELATED APPLICATION(S)

This application claims the benefit of U.S. Provisional Application No.62/736,746, filed Sep. 26, 2018, which is hereby incorporated byreference in its entirety.

TECHNICAL FIELD

The systems and methods disclosed herein are directed to a medicalinstrument, and in particular, to medical instrument capable of multiplefunctions.

BACKGROUND

Medical procedures, such as laparoscopy, may involve accessing andvisualizing an internal region of a patient. In a laparoscopicprocedure, a medical instrument can be inserted into the internal regionthrough a laparoscopic access port.

In certain procedures, a robotically-enabled medical system may be usedto control the insertion and/or manipulation of the medical instrumentand end effector. The robotically-enabled medical system may include arobotic arm or any other instrument positioning device. Therobotically-enabled medical system may also include a controller used tocontrol the positioning of the instrument during the procedure.

SUMMARY

In a first aspect, a multi-functional surgical instrument comprises anelongate shaft extending between a proximal end and a distal end, awrist extending from the distal end of the elongate shaft, and an endeffector extending from the wrist, and a tube extending through theelongate shaft and the wrist, the tube having an outlet in fluidcommunication with a passage formed by an interior of the first andsecond jaws when the jaws are in the closed position. The end effectorcomprises a first jaw and a second jaw, the first and second jaw beingmoveable between an open position in which ends of the jaws areseparated from each other and a closed position in which the ends of thejaws are closer to each other as compared to the open position.

The surgical instrument may further include one or more of the followingfeatures in any combination: (a) wherein the tube extends at leastpartially between the first and second jaws; (b) wherein a portion ofthe tube extending between the first and second jaws is a flexible tube;(c) wherein the flexible tube is between 4 and 6 millimeters in length;(d) wherein the tube is in communication with an irrigation and fluidsource; (e) wherein the wrist comprises a distal clevis that comprisescurved surfaces to support at least one pivot axis; (f) furthercomprising a first pivot pin that is pivotably supported within thefirst cup shaped opening and a second pivot pin that is pivotablysupported within the second cup shaped opening; (g) wherein at least onepivot pin structure couples the first jaw to the second jaw; (h) whereinthe wrist comprises a proximal clevis and a distal clevis; (i) whereinthe distal clevis forms in part a first joint about which the first andsecond jaw can rotate and the proximal clevis forms a second joint aboutwhich the wrist can pivot with respect to the elongate shaft;(j) whereinthe first joint is a different type of joint from the second joint; (k)wherein the second joint comprises a rolling joint and the first jointcomprises a pin joint; (l) wherein the elongated shaft comprises ahandle including one or more inputs, wherein at least one of the inputsenables robotic control of irrigation and/or suction capabilities of thetube; and/or (m) wherein the at least one input is coupled to a capstancapable of pinching one or both of an irrigation line and a suctionline.

In another aspect, a surgical instrument comprises an elongate shaftextending between a proximal end and a distal end; a wrist extendingfrom the distal end of the elongate shaft, the wrist comprising a distalclevis and a proximal clevis, the distal clevis comprising a distalrecess; and an end effector extending from the wrist. The end effectorcomprising a first jaw and a second jaw, and at least one pin jointformed between the first jaw and the second jaw, wherein the at leastone pin joint is supported by the distal recess.

The surgical instrument may further include one or more of the followingfeatures in any combination: (a) wherein the at least one pin joint isformed by a first pin that extends from the first jaw into an opening inthe second jaw; (b) wherein the distal recess is formed by an uppersurface of the wrist; (c) wherein the distal recess is cup-shaped; (d)wherein a rolling joint is formed between the proximal clevis and thedistal clevis; (e) wherein the rolling comprises a cycloid joint; (f)further comprising an elongate tube extending through the elongate shaftand the wrist, the tube having an outlet in fluid communication with apassage formed by the first and second members; and/or (g) wherein thetube is flexible.

In another aspect, a method of using a multi-functional medicalinstrument, the method comprises (i) inserting a distal end of themedical instrument into a patient, (ii) using the medical instrument togrip tissue within the patient, and (iii) using the medical instrumentto perform a suction or irrigation procedure within the patient.

The method may further include one or more of the following features inany combination: (a) using the first instrument to grip tissue withinthe patient and the second instrument to grip tissue within the patient;(b) using the first instrument to grip tissue adjacent to a surgicalsite and the second instrument to grip tissue at the surgical site; (c)maneuvering the second instrument to grip tissue adjacent to thesurgical site and maneuvering the first instrument to perform a suctionor irrigation procedure at the surgical site; (d) wherein the firstinstrument remains docked to the first cannula and the second instrumentremains docked to the second cannula.

BRIEF DESCRIPTION OF THE DRAWINGS

The disclosed aspects will hereinafter be described in conjunction withthe appended drawings, provided to illustrate and not to limit thedisclosed aspects, wherein like designations denote like elements.

FIG. 1 illustrates an embodiment of a cart-based robotic system arrangedfor diagnostic and/or therapeutic bronchoscopy.

FIG. 2 depicts further aspects of the robotic system of FIG. 1 .

FIG. 3 illustrates an embodiment of the robotic system of FIG. 1arranged for ureteroscopy.

FIG. 4 illustrates an embodiment of the robotic system of FIG. 1arranged for a vascular procedure.

FIG. 5 illustrates an embodiment of a table-based robotic systemarranged for a bronchoscopic procedure.

FIG. 6 provides an alternative view of the robotic system of FIG. 5 .

FIG. 7 illustrates an example system configured to stow robotic arm(s).

FIG. 8 illustrates an embodiment of a table-based robotic systemconfigured for a ureteroscopic procedure.

FIG. 9 illustrates an embodiment of a table-based robotic systemconfigured for a laparoscopic procedure.

FIG. 10 illustrates an embodiment of the table-based robotic system ofFIGS. 5-9 with pitch or tilt adjustment.

FIG. 11 provides a detailed illustration of the interface between thetable and the column of the table-based robotic system of FIGS. 5-10 .

FIG. 12 illustrates an alternative embodiment of a table-based roboticsystem.

FIG. 13 illustrates an end view of the table-based robotic system ofFIG. 12 .

FIG. 14 illustrates an end view of a table-based robotic system withrobotic arms attached thereto.

FIG. 15 illustrates an exemplary instrument driver.

FIG. 16 illustrates an exemplary medical instrument with a pairedinstrument driver.

FIG. 17 illustrates an alternative design for an instrument driver andinstrument where the axes of the drive units are parallel to the axis ofthe elongated shaft of the instrument.

FIG. 18 illustrates an instrument having an instrument-based insertionarchitecture.

FIG. 19 illustrates an exemplary controller.

FIG. 20 depicts a block diagram illustrating a localization system thatestimates a location of one or more elements of the robotic systems ofFIGS. 1-10 , such as the location of the instrument of FIGS. 16-18 , inaccordance to an example embodiment.

FIG. 21 illustrates a side view of a surgical instrument.

FIG. 22A illustrates a perspective view of an embodiment of a surgicalinstrument.

FIG. 22B illustrates a side view of an embodiment of the surgicalinstrument shown in FIG. 22A.

FIG. 22C illustrates a front view of an embodiment of the surgicalinstrument shown in FIGS. 22A-22B.

FIG. 23A illustrates a perspective view of the cables of a surgicalinstrument.

FIG. 23B illustrates a perspective view of the surgical instrument ofFIGS. 22A-C, showing rotation of two jaw halves about a yaw axis androtation of a surgical effector about a pitch axis.

FIG. 23C illustrates a perspective view of the surgical instrument ofFIGS. 22A-C, showing another rotation of two jaw halves about a yaw axisand rotation of a surgical effector about a pitch axis.

FIG. 24A illustrates a perspective view of the surgical effector of asurgical instrument, showing rotation of two jaw halves about a yawaxis.

FIG. 24B illustrates a side view of the surgical instrument of FIG. 24A,with the entire shaft and suction/irrigation lines shown.

FIG. 25A illustrates a perspective view of a first jaw half of thesurgical effector of a surgical instrument of FIG. 24 .

FIG. 25B illustrates another perspective view of a first jaw half of thesurgical effector of a surgical instrument of FIG. 24 .

FIG. 25C illustrates a cross sectional view of the connection of asurgical effector and distal clevis of FIG. 24 .

FIG. 26A illustrates a top, perspective view of the a distal clevis of awrist of a surgical instrument.

FIG. 26B illustrates a top view of a distal clevis of FIG. 26A.

FIG. 26C illustrates a bottom, perspective view of a distal clevis ofFIG. 26A.

FIG. 26D illustrates a bottom view of a distal clevis of FIG. 26A.

FIG. 26E illustrates a side view of a distal clevis of FIG. 26A.

FIG. 26F illustrates a side view of a distal clevis of FIG. 26A.

FIG. 27A illustrates a top, perspective view of the a proximal clevis ofa wrist of a surgical instrument.

FIG. 27B illustrates a top view of a proximal clevis of FIG. 27A.

FIG. 27C illustrates a bottom, perspective view of a proximal clevis ofFIG. 27A.

FIG. 27D illustrates a bottom view of a proximal clevis of FIG. 27A.

FIG. 27E illustrates a front view of a proximal clevis of FIG. 27A.

FIG. 27F illustrates a side view of a proximal clevis of FIG. 27A.

FIG. 28 illustrates a method of use of a surgical instrument at asurgical site.

DETAILED DESCRIPTION

1. Overview.

Aspects of the present disclosure may be integrated into arobotically-enabled medical system capable of performing a variety ofmedical procedures, including both minimally invasive, such aslaparoscopy, and non-invasive, such as endoscopy, procedures. Amongendoscopic procedures, the system may be capable of performingbronchoscopy, ureteroscopy, gastroscopy, etc.

In addition to performing the breadth of procedures, the system mayprovide additional benefits, such as enhanced imaging and guidance toassist the physician. Additionally, the system may provide the physicianwith the ability to perform the procedure from an ergonomic positionwithout the need for awkward arm motions and positions. Still further,the system may provide the physician with the ability to perform theprocedure with improved ease of use such that one or more of theinstruments of the system can be controlled by a single user.

Various embodiments will be described below in conjunction with thedrawings for purposes of illustration. It should be appreciated thatmany other implementations of the disclosed concepts are possible, andvarious advantages can be achieved with the disclosed implementations.Headings are included herein for reference and to aid in locatingvarious sections. These headings are not intended to limit the scope ofthe concepts described with respect thereto. Such concepts may haveapplicability throughout the entire specification.

A. Robotic System—Cart.

The robotically-enabled medical system may be configured in a variety ofways depending on the particular procedure. FIG. 1 illustrates anembodiment of a cart-based robotically-enabled system 10 arranged for adiagnostic and/or therapeutic bronchoscopy. During a bronchoscopy, thesystem 10 may comprise a cart 11 having one or more robotic arms 12 todeliver a medical instrument, such as a steerable endoscope 13, whichmay be a procedure-specific bronchoscope for bronchoscopy, to a naturalorifice access point (i.e., the mouth of the patient positioned on atable in the present example) to deliver diagnostic and/or therapeutictools. As shown, the cart 11 may be positioned proximate to thepatient's upper torso in order to provide access to the access point.Similarly, the robotic arms 12 may be actuated to position thebronchoscope relative to the access point. The arrangement in FIG. 1 mayalso be utilized when performing a gastro-intestinal (GI) procedure witha gastroscope, a specialized endoscope for GI procedures. FIG. 2 depictsan example embodiment of the cart in greater detail.

With continued reference to FIG. 1 , once the cart 11 is properlypositioned, the robotic arms 12 may insert the steerable endoscope 13into the patient robotically, manually, or a combination thereof. Asshown, the steerable endoscope 13 may comprise at least two telescopingparts, such as an inner leader portion and an outer sheath portion, eachportion coupled to a separate instrument driver from the set ofinstrument drivers 28, each instrument driver coupled to the distal endof an individual robotic arm. This linear arrangement of the instrumentdrivers 28, which facilitates coaxially aligning the leader portion withthe sheath portion, creates a “virtual rail” 29 that may be repositionedin space by manipulating the one or more robotic arms 12 into differentangles and/or positions. The virtual rails described herein are depictedin the Figures using dashed lines, and accordingly the dashed lines donot depict any physical structure of the system. Translation of theinstrument drivers 28 along the virtual rail 29 telescopes the innerleader portion relative to the outer sheath portion or advances orretracts the endoscope 13 from the patient. The angle of the virtualrail 29 may be adjusted, translated, and pivoted based on clinicalapplication or physician preference. For example, in bronchoscopy, theangle and position of the virtual rail 29 as shown represents acompromise between providing physician access to the endoscope 13 whileminimizing friction that results from bending the endoscope 13 into thepatient's mouth.

The endoscope 13 may be directed down the patient's trachea and lungsafter insertion using precise commands from the robotic system untilreaching the target destination or operative site. In order to enhancenavigation through the patient's lung network and/or reach the desiredtarget, the endoscope 13 may be manipulated to telescopically extend theinner leader portion from the outer sheath portion to obtain enhancedarticulation and greater bend radius. The use of separate instrumentdrivers 28 also allows the leader portion and sheath portion to bedriven independently of each other.

For example, the endoscope 13 may be directed to deliver a biopsy needleto a target, such as, for example, a lesion or nodule within the lungsof a patient. The needle may be deployed down a working channel thatruns the length of the endoscope to obtain a tissue sample to beanalyzed by a pathologist. Depending on the pathology results,additional tools may be deployed down the working channel of theendoscope for additional biopsies. After identifying a nodule to bemalignant, the endoscope 13 may endoscopically deliver tools to resectthe potentially cancerous tissue. In some instances, diagnostic andtherapeutic treatments can be delivered in separate procedures. In thosecircumstances, the endoscope 13 may also be used to deliver a fiducialto “mark” the location of the target nodule as well. In other instances,diagnostic and therapeutic treatments may be delivered during the sameprocedure.

The system 10 may also include a movable tower 30, which may beconnected via support cables to the cart 11 to provide support forcontrols, electronics, fluidics, optics, sensors, and/or power to thecart 11. Placing such functionality in the tower 30 allows for a smallerform factor cart 11 that may be more easily adjusted and/orre-positioned by an operating physician and his/her staff. Additionally,the division of functionality between the cart/table and the supporttower 30 reduces operating room clutter and facilitates improvingclinical workflow. While the cart 11 may be positioned close to thepatient, the tower 30 may be stowed in a remote location to stay out ofthe way during a procedure.

In support of the robotic systems described above, the tower 30 mayinclude component(s) of a computer-based control system that storescomputer program instructions, for example, within a non-transitorycomputer-readable storage medium such as a persistent magnetic storagedrive, solid state drive, etc. The execution of those instructions,whether the execution occurs in the tower 30 or the cart 11, may controlthe entire system or sub-system(s) thereof. For example, when executedby a processor of the computer system, the instructions may cause thecomponents of the robotics system to actuate the relevant carriages andarm mounts, actuate the robotics arms, and control the medicalinstruments. For example, in response to receiving the control signal,the motors in the joints of the robotics arms may position the arms intoa certain posture.

The tower 30 may also include a pump, flow meter, valve control, and/orfluid access in order to provide controlled irrigation and aspirationcapabilities to the system that may be deployed through the endoscope13. These components may also be controlled using the computer system ofthe tower 30. In some embodiments, irrigation and aspirationcapabilities may be delivered directly to the endoscope 13 throughseparate cable(s).

The tower 30 may include a voltage and surge protector designed toprovide filtered and protected electrical power to the cart 11, therebyavoiding placement of a power transformer and other auxiliary powercomponents in the cart 11, resulting in a smaller, more moveable cart11.

The tower 30 may also include support equipment for the sensors deployedthroughout the robotic system 10. For example, the tower 30 may includeoptoelectronics equipment for detecting, receiving, and processing datareceived from the optical sensors or cameras throughout the roboticsystem 10. In combination with the control system, such optoelectronicsequipment may be used to generate real-time images for display in anynumber of consoles deployed throughout the system, including in thetower 30. Similarly, the tower 30 may also include an electronicsubsystem for receiving and processing signals received from deployedelectromagnetic (EM) sensors. The tower 30 may also be used to house andposition an EM field generator for detection by EM sensors in or on themedical instrument.

The tower 30 may also include a console 31 in addition to other consolesavailable in the rest of the system, e.g., console mounted on top of thecart. The console 31 may include a user interface and a display screen,such as a touchscreen, for the physician operator. Consoles in thesystem 10 are generally designed to provide both robotic controls aswell as pre-operative and real-time information of the procedure, suchas navigational and localization information of the endoscope 13. Whenthe console 31 is not the only console available to the physician, itmay be used by a second operator, such as a nurse, to monitor the healthor vitals of the patient and the operation of the system 10, as well asto provide procedure-specific data, such as navigational andlocalization information. In other embodiments, the console 30 is housedin a body that is separate from the tower 30.

The tower 30 may be coupled to the cart 11 and endoscope 13 through oneor more cables or connections (not shown). In some embodiments, thesupport functionality from the tower 30 may be provided through a singlecable to the cart 11, simplifying and de-cluttering the operating room.In other embodiments, specific functionality may be coupled in separatecabling and connections. For example, while power may be providedthrough a single power cable to the cart 11, the support for controls,optics, fluidics, and/or navigation may be provided through a separatecable.

FIG. 2 provides a detailed illustration of an embodiment of the cart 11from the cart-based robotically-enabled system shown in FIG. 1 . Thecart 11 generally includes an elongated support structure 14 (oftenreferred to as a “column”), a cart base 15, and a console 16 at the topof the column 14. The column 14 may include one or more carriages, suchas a carriage 17 (alternatively “arm support”) for supporting thedeployment of one or more robotic arms 12 (three shown in FIG. 2 ). Thecarriage 17 may include individually configurable arm mounts that rotatealong a perpendicular axis to adjust the base of the robotic arms 12 forbetter positioning relative to the patient. The carriage 17 alsoincludes a carriage interface 19 that allows the carriage 17 tovertically translate along the column 14.

The carriage interface 19 is connected to the column 14 through slots,such as slot 20, that are positioned on opposite sides of the column 14to guide the vertical translation of the carriage 17. The slot 20contains a vertical translation interface to position and hold thecarriage 17 at various vertical heights relative to the cart base 15.Vertical translation of the carriage 17 allows the cart 11 to adjust thereach of the robotic arms 12 to meet a variety of table heights, patientsizes, and physician preferences. Similarly, the individuallyconfigurable arm mounts on the carriage 17 allow the robotic arm base 21of the robotic arms 12 to be angled in a variety of configurations.

In some embodiments, the slot 20 may be supplemented with slot coversthat are flush and parallel to the slot surface to prevent dirt andfluid ingress into the internal chambers of the column 14 and thevertical translation interface as the carriage 17 vertically translates.The slot covers may be deployed through pairs of spring spoolspositioned near the vertical top and bottom of the slot 20. The coversare coiled within the spools until deployed to extend and retract fromtheir coiled state as the carriage 17 vertically translates up and down.The spring-loading of the spools provides force to retract the coverinto a spool when the carriage 17 translates towards the spool, whilealso maintaining a tight seal when the carriage 17 translates away fromthe spool. The covers may be connected to the carriage 17 using, forexample, brackets in the carriage interface 19 to ensure properextension and retraction of the cover as the carriage 17 translates.

The column 14 may internally comprise mechanisms, such as gears andmotors, that are designed to use a vertically aligned lead screw totranslate the carriage 17 in a mechanized fashion in response to controlsignals generated in response to user inputs, e.g., inputs from theconsole 16.

The robotic arms 12 may generally comprise robotic arm bases 21 and endeffectors 22, separated by a series of linkages 23 that are connected bya series of joints 24, each joint comprising an independent actuator,each actuator comprising an independently controllable motor. Eachindependently controllable joint represents an independent degree offreedom available to the robotic arm 12. Each of the robotic arms 12 mayhave seven joints, and thus provide seven degrees of freedom. Amultitude of joints result in a multitude of degrees of freedom,allowing for “redundant” degrees of freedom. Having redundant degrees offreedom allows the robotic arms 12 to position their respective endeffectors 22 at a specific position, orientation, and trajectory inspace using different linkage positions and joint angles. This allowsfor the system to position and direct a medical instrument from adesired point in space while allowing the physician to move the armjoints into a clinically advantageous position away from the patient tocreate greater access, while avoiding arm collisions.

The cart base 15 balances the weight of the column 14, carriage 17, androbotic arms 12 over the floor. Accordingly, the cart base 15 housesheavier components, such as electronics, motors, power supply, as wellas components that either enable movement and/or immobilize the cart 11.For example, the cart base 15 includes rollable wheel-shaped casters 25that allow for the cart 11 to easily move around the room prior to aprocedure. After reaching the appropriate position, the casters 25 maybe immobilized using wheel locks to hold the cart 11 in place during theprocedure.

Positioned at the vertical end of the column 14, the console 16 allowsfor both a user interface for receiving user input and a display screen(or a dual-purpose device such as, for example, a touchscreen 26) toprovide the physician user with both pre-operative and intra-operativedata. Potential pre-operative data on the touchscreen 26 may includepre-operative plans, navigation and mapping data derived frompre-operative computerized tomography (CT) scans, and/or notes frompre-operative patient interviews. Intra-operative data on display mayinclude optical information provided from the tool, sensor andcoordinate information from sensors, as well as vital patientstatistics, such as respiration, heart rate, and/or pulse. The console16 may be positioned and tilted to allow a physician to access theconsole from the side of the column 14 opposite the carriage 17. Fromthis position, the physician may view the console 16, robotic arms 12,and patient while operating the console 16 from behind the cart 11. Asshown, the console 16 also includes a handle 27 to assist withmaneuvering and stabilizing the cart 11.

FIG. 3 illustrates an embodiment of a robotically-enabled system 10arranged for ureteroscopy. In a ureteroscopic procedure, the cart 11 maybe positioned to deliver a ureteroscope 32, a procedure-specificendoscope designed to traverse a patient's urethra and ureter, to thelower abdominal area of the patient. In a ureteroscopy, it may bedesirable for the ureteroscope 32 to be directly aligned with thepatient's urethra to reduce friction and forces on the sensitive anatomyin the area. As shown, the cart 11 may be aligned at the foot of thetable to allow the robotic arms 12 to position the ureteroscope 32 fordirect linear access to the patient's urethra. From the foot of thetable, the robotic arms 12 may insert the ureteroscope 32 along thevirtual rail 33 directly into the patient's lower abdomen through theurethra.

After insertion into the urethra, using similar control techniques as inbronchoscopy, the ureteroscope 32 may be navigated into the bladder,ureters, and/or kidneys for diagnostic and/or therapeutic applications.For example, the ureteroscope 32 may be directed into the ureter andkidneys to break up kidney stone build up using a laser or ultrasoniclithotripsy device deployed down the working channel of the ureteroscope32. After lithotripsy is complete, the resulting stone fragments may beremoved using baskets deployed down the ureteroscope 32.

FIG. 4 illustrates an embodiment of a robotically-enabled systemsimilarly arranged for a vascular procedure. In a vascular procedure,the system 10 may be configured such that the cart 11 may deliver amedical instrument 34, such as a steerable catheter, to an access pointin the femoral artery in the patient's leg. The femoral artery presentsboth a larger diameter for navigation as well as a relatively lesscircuitous and tortuous path to the patient's heart, which simplifiesnavigation. As in a ureteroscopic procedure, the cart 11 may bepositioned towards the patient's legs and lower abdomen to allow therobotic arms 12 to provide a virtual rail 35 with direct linear accessto the femoral artery access point in the patient's thigh/hip region.After insertion into the artery, the medical instrument 34 may bedirected and inserted by translating the instrument drivers 28.Alternatively, the cart may be positioned around the patient's upperabdomen in order to reach alternative vascular access points, such as,for example, the carotid and brachial arteries near the shoulder andwrist.

B. Robotic System—Table.

Embodiments of the robotically-enabled medical system may alsoincorporate the patient's table. Incorporation of the table reduces theamount of capital equipment within the operating room by removing thecart, which allows greater access to the patient. FIG. 5 illustrates anembodiment of such a robotically-enabled system arranged for abronchoscopic. System 36 includes a support structure or column 37 forsupporting platform 38 (shown as a “table” or “bed”) over the floor.Much like in the cart-based systems, the end effectors of the roboticarms 39 of the system 36 comprise instrument drivers 42 that aredesigned to manipulate an elongated medical instrument, such as abronchoscope 40 in FIG. 5 , through or along a virtual rail 41 formedfrom the linear alignment of the instrument drivers 42. In practice, aC-arm for providing fluoroscopic imaging may be positioned over thepatient's upper abdominal area by placing the emitter and detectoraround the table 38.

FIG. 6 provides an alternative view of the system 36 without the patientand medical instrument for discussion purposes. As shown, the column 37may include one or more carriages 43 shown as ring-shaped in the system36, from which the one or more robotic arms 39 may be based. Thecarriages 43 may translate along a vertical column interface 44 thatruns the length of the column 37 to provide different vantage pointsfrom which the robotic arms 39 may be positioned to reach the patient.The carriage(s) 43 may rotate around the column 37 using a mechanicalmotor positioned within the column 37 to allow the robotic arms 39 tohave access to multiples sides of the table 38, such as, for example,both sides of the patient. In embodiments with multiple carriages, thecarriages may be individually positioned on the column and may translateand/or rotate independently of the other carriages. While the carriages43 need not surround the column 37 or even be circular, the ring-shapeas shown facilitates rotation of the carriages 43 around the column 37while maintaining structural balance. Rotation and translation of thecarriages 43 allows the system 36 to align the medical instruments, suchas endoscopes and laparoscopes, into different access points on thepatient. In other embodiments (not shown), the system 36 can include apatient table or bed with adjustable arm supports in the form of bars orrails extending alongside it. One or more robotic arms 39 (e.g., via ashoulder with an elbow joint) can be attached to the adjustable armsupports, which can be vertically adjusted. By providing verticaladjustment, the robotic arms 39 are advantageously capable of beingstowed compactly beneath the patient table or bed, and subsequentlyraised during a procedure.

The robotic arms 39 may be mounted on the carriages through a set of armmounts 45 comprising a series of joints that may individually rotateand/or telescopically extend to provide additional configurability tothe robotic arms 39. Additionally, the arm mounts 45 may be positionedon the carriages 43 such that, when the carriages 43 are appropriatelyrotated, the arm mounts 45 may be positioned on either the same side ofthe table 38 (as shown in FIG. 6 ), on opposite sides of table 38 (asshown in FIG. 9 ), or on adjacent sides of the table 38 (not shown).

The column 37 structurally provides support for the table 38, and a pathfor vertical translation of the carriages 43. Internally, the column 37may be equipped with lead screws for guiding vertical translation of thecarriages, and motors to mechanize the translation of the carriages 43based the lead screws. The column 37 may also convey power and controlsignals to the carriage 43 and the robotic arms 39 mounted thereon.

The table base 46 serves a similar function as the cart base 15 in cart11 shown in FIG. 2 , housing heavier components to balance the table/bed38, the column 37, the carriages 43, and the robotic arms 39. The tablebase 46 may also incorporate rigid casters to provide stability duringprocedures. Deployed from the bottom of the table base 46, the castersmay extend in opposite directions on both sides of the base 46 andretract when the system 36 needs to be moved.

With continued reference to FIG. 6 , the system 36 may also include atower (not shown) that divides the functionality of the system 36between the table and the tower to reduce the form factor and bulk ofthe table. As in earlier disclosed embodiments, the tower may provide avariety of support functionalities to the table, such as processing,computing, and control capabilities, power, fluidics, and/or optical andsensor processing. The tower may also be movable to be positioned awayfrom the patient to improve physician access and de-clutter theoperating room. Additionally, placing components in the tower allows formore storage space in the table base 46 for potential stowage of therobotic arms 39. The tower may also include a master controller orconsole that provides both a user interface for user input, such askeyboard and/or pendant, as well as a display screen (or touchscreen)for pre-operative and intra-operative information, such as real-timeimaging, navigation, and tracking information. In some embodiments, thetower may also contain holders for gas tanks to be used forinsufflation.

In some embodiments, a table base may stow and store the robotic armswhen not in use. FIG. 7 illustrates a system 47 that stows robotic armsin an embodiment of the table-based system. In the system 47, carriages48 may be vertically translated into base 49 to stow robotic arms 50,arm mounts 51, and the carriages 48 within the base 49. Base covers 52may be translated and retracted open to deploy the carriages 48, armmounts 51, and robotic arms 50 around column 53, and closed to stow toprotect them when not in use. The base covers 52 may be sealed with amembrane 54 along the edges of its opening to prevent dirt and fluidingress when closed.

FIG. 8 illustrates an embodiment of a robotically-enabled table-basedsystem configured for a ureteroscopic procedure. In a ureteroscopy, thetable 38 may include a swivel portion 55 for positioning a patientoff-angle from the column 37 and table base 46. The swivel portion 55may rotate or pivot around a pivot point (e.g., located below thepatient's head) in order to position the bottom portion of the swivelportion 55 away from the column 37. For example, the pivoting of theswivel portion 55 allows a C-arm (not shown) to be positioned over thepatient's lower abdomen without competing for space with the column (notshown) below table 38. By rotating the carriage 35 (not shown) aroundthe column 37, the robotic arms 39 may directly insert a ureteroscope 56along a virtual rail 57 into the patient's groin area to reach theurethra. In a ureteroscopy, stirrups 58 may also be fixed to the swivelportion 55 of the table 38 to support the position of the patient's legsduring the procedure and allow clear access to the patient's groin area.

In a laparoscopic procedure, through small incision(s) in the patient'sabdominal wall, minimally invasive instruments may be inserted into thepatient's anatomy. In some embodiments, the minimally invasiveinstruments comprise an elongated rigid member, such as a shaft, whichis used to access anatomy within the patient. After inflation of thepatient's abdominal cavity, the instruments may be directed to performsurgical or medical tasks, such as grasping, cutting, ablating,suturing, etc. In some embodiments, the instruments can comprise ascope, such as a laparoscope. FIG. 9 illustrates an embodiment of arobotically-enabled table-based system configured for a laparoscopicprocedure. As shown in FIG. 9 , the carriages 43 of the system 36 may berotated and vertically adjusted to position pairs of the robotic arms 39on opposite sides of the table 38, such that instrument 59 may bepositioned using the arm mounts 45 to be passed through minimalincisions on both sides of the patient to reach his/her abdominalcavity.

To accommodate laparoscopic procedures, the robotically-enabled tablesystem may also tilt the platform to a desired angle. FIG. 10illustrates an embodiment of the robotically-enabled medical system withpitch or tilt adjustment. As shown in FIG. 10 , the system 36 mayaccommodate tilt of the table 38 to position one portion of the table ata greater distance from the floor than the other. Additionally, the armmounts 45 may rotate to match the tilt such that the robotic arms 39maintain the same planar relationship with table 38. To accommodatesteeper angles, the column 37 may also include telescoping portions 60that allow vertical extension of the column 37 to keep the table 38 fromtouching the floor or colliding with the table base 46.

FIG. 11 provides a detailed illustration of the interface between thetable 38 and the column 37. Pitch rotation mechanism 61 may beconfigured to alter the pitch angle of the table 38 relative to thecolumn 37 in multiple degrees of freedom. The pitch rotation mechanism61 may be enabled by the positioning of orthogonal axes 1, 2 at thecolumn-table interface, each axis actuated by a separate motor 3, 4responsive to an electrical pitch angle command. Rotation along onescrew 5 would enable tilt adjustments in one axis 1, while rotationalong the other screw 6 would enable tilt adjustments along the otheraxis 2. In some embodiments, a ball joint can be used to alter the pitchangle of the table 38 relative to the column 37 in multiple degrees offreedom.

For example, pitch adjustments are particularly useful when trying toposition the table in a Trendelenburg position, i.e., position thepatient's lower abdomen at a higher position from the floor than thepatient's lower abdomen, for upper abdominal surgery. The Trendelenburgposition causes the patient's internal organs to slide towards his/herupper abdomen through the force of gravity, clearing out the abdominalcavity for minimally invasive tools to enter and perform lower abdominalsurgical or medical procedures, such as laparoscopic prostatectomy.

FIGS. 12 and 13 illustrate isometric and end views of an alternativeembodiment of a table-based surgical robotics system 100. The surgicalrobotics system 100 includes one or more adjustable arm supports 105that can be configured to support one or more robotic arms (see, forexample, FIG. 14 ) relative to a table 101. In the illustratedembodiment, a single adjustable arm support 105 is shown, though anadditional arm support can be provided on an opposite side of the table101. The adjustable arm support 105 can be configured so that it canmove relative to the table 101 to adjust and/or vary the position of theadjustable arm support 105 and/or any robotic arms mounted theretorelative to the table 101. For example, the adjustable arm support 105may be adjusted one or more degrees of freedom relative to the table101. The adjustable arm support 105 provides high versatility to thesystem 100, including the ability to easily stow the one or moreadjustable arm supports 105 and any robotics arms attached theretobeneath the table 101. The adjustable arm support 105 can be elevatedfrom the stowed position to a position below an upper surface of thetable 101. In other embodiments, the adjustable arm support 105 can beelevated from the stowed position to a position above an upper surfaceof the table 101.

The adjustable arm support 105 can provide several degrees of freedom,including lift, lateral translation, tilt, etc. In the illustratedembodiment of FIGS. 12 and 13 , the arm support 105 is configured withfour degrees of freedom, which are illustrated with arrows in FIG. 12 .A first degree of freedom allows for adjustment of the adjustable armsupport 105 in the z-direction (“Z-lift”). For example, the adjustablearm support 105 can include a carriage 109 configured to move up or downalong or relative to a column 102 supporting the table 101. A seconddegree of freedom can allow the adjustable arm support 105 to tilt. Forexample, the adjustable arm support 105 can include a rotary joint,which can allow the adjustable arm support 105 to be aligned with thebed in a Trendelenburg position. A third degree of freedom can allow theadjustable arm support 105 to “pivot up,” which can be used to adjust adistance between a side of the table 101 and the adjustable arm support105. A fourth degree of freedom can permit translation of the adjustablearm support 105 along a longitudinal length of the table.

The surgical robotics system 100 in FIGS. 12 and 13 can comprise a tablesupported by a column 102 that is mounted to a base 103. The base 103and the column 102 support the table 101 relative to a support surface.A floor axis 131 and a support axis 133 are shown in FIG. 13 .

The adjustable arm support 105 can be mounted to the column 102. Inother embodiments, the arm support 105 can be mounted to the table 101or base 103. The adjustable arm support 105 can include a carriage 109,a bar or rail connector 111 and a bar or rail 107. In some embodiments,one or more robotic arms mounted to the rail 107 can translate and moverelative to one another.

The carriage 109 can be attached to the column 102 by a first joint 113,which allows the carriage 109 to move relative to the column 102 (e.g.,such as up and down a first or vertical axis 123). The first joint 113can provide the first degree of freedom (“Z-lift”) to the adjustable armsupport 105. The adjustable arm support 105 can include a second joint115, which provides the second degree of freedom (tilt) for theadjustable arm support 105. The adjustable arm support 105 can include athird joint 117, which can provide the third degree of freedom (“pivotup”) for the adjustable arm support 105. An additional joint 119 (shownin FIG. 13 ) can be provided that mechanically constrains the thirdjoint 117 to maintain an orientation of the rail 107 as the railconnector 111 is rotated about a third axis 127. The adjustable armsupport 105 can include a fourth joint 121, which can provide a fourthdegree of freedom (translation) for the adjustable arm support 105 alonga fourth axis 129.

FIG. 14 illustrates an end view of the surgical robotics system 140Awith two adjustable arm supports 105A, 105B mounted on opposite sides ofa table 101. A first robotic arm 142A is attached to the bar or rail107A of the first adjustable arm support 105B. The first robotic arm142A includes a base 144A attached to the rail 107A. The distal end ofthe first robotic arm 142A includes an instrument drive mechanism 146Athat can attach to one or more robotic medical instruments or tools.Similarly, the second robotic arm 142B includes a base 144B attached tothe rail 107B. The distal end of the second robotic arm 142B includes aninstrument drive mechanism 146B. The instrument drive mechanism 146B canbe configured to attach to one or more robotic medical instruments ortools.

In some embodiments, one or more of the robotic arms 142A, 142Bcomprises an arm with seven or more degrees of freedom. In someembodiments, one or more of the robotic arms 142A, 142B can includeeight degrees of freedom, including an insertion axis (1-degree offreedom including insertion), a wrist (3-degrees of freedom includingwrist pitch, yaw and roll), an elbow (1-degree of freedom includingelbow pitch), a shoulder (2-degrees of freedom including shoulder pitchand yaw), and base 144A, 144B (1-degree of freedom includingtranslation). In some embodiments, the insertion degree of freedom canbe provided by the robotic arm 142A, 142B, while in other embodiments,the instrument itself provides insertion via an instrument-basedinsertion architecture.

C. Instrument Driver & Interface.

The end effectors of the system's robotic arms may comprise (i) aninstrument driver (alternatively referred to as “instrument drivemechanism” or “instrument device manipulator”) that incorporateselectro-mechanical means for actuating the medical instrument and (ii) aremovable or detachable medical instrument, which may be devoid of anyelectro-mechanical components, such as motors. This dichotomy may bedriven by the need to sterilize medical instruments used in medicalprocedures, and the inability to adequately sterilize expensive capitalequipment due to their intricate mechanical assemblies and sensitiveelectronics. Accordingly, the medical instruments may be designed to bedetached, removed, and interchanged from the instrument driver (and thusthe system) for individual sterilization or disposal by the physician orthe physician's staff. In contrast, the instrument drivers need not bechanged or sterilized, and may be draped for protection.

FIG. 15 illustrates an example instrument driver. Positioned at thedistal end of a robotic arm, instrument driver 62 comprises of one ormore drive units 63 arranged with parallel axes to provide controlledtorque to a medical instrument via drive shafts 64. Each drive unit 63comprises an individual drive shaft 64 for interacting with theinstrument, a gear head 65 for converting the motor shaft rotation to adesired torque, a motor 66 for generating the drive torque, an encoder67 to measure the speed of the motor shaft and provide feedback to thecontrol circuitry, and control circuity 68 for receiving control signalsand actuating the drive unit. Each drive unit 63 being independentlycontrolled and motorized, the instrument driver 62 may provide multiple(four as shown in FIG. 15 ) independent drive outputs to the medicalinstrument. In operation, the control circuitry 68 would receive acontrol signal, transmit a motor signal to the motor 66, compare theresulting motor speed as measured by the encoder 67 with the desiredspeed, and modulate the motor signal to generate the desired torque.

For procedures that require a sterile environment, the robotic systemmay incorporate a drive interface, such as a sterile adapter connectedto a sterile drape, that sits between the instrument driver and themedical instrument. The chief purpose of the sterile adapter is totransfer angular motion from the drive shafts of the instrument driverto the drive inputs of the instrument while maintaining physicalseparation, and thus sterility, between the drive shafts and driveinputs. Accordingly, an example sterile adapter may comprise of a seriesof rotational inputs and outputs intended to be mated with the driveshafts of the instrument driver and drive inputs on the instrument.Connected to the sterile adapter, the sterile drape, comprised of athin, flexible material such as transparent or translucent plastic, isdesigned to cover the capital equipment, such as the instrument driver,robotic arm, and cart (in a cart-based system) or table (in atable-based system). Use of the drape would allow the capital equipmentto be positioned proximate to the patient while still being located inan area not requiring sterilization (i.e., non-sterile field). On theother side of the sterile drape, the medical instrument may interfacewith the patient in an area requiring sterilization (i.e., sterilefield).

D. Medical Instrument.

FIG. 16 illustrates an example medical instrument with a pairedinstrument driver. Like other instruments designed for use with arobotic system, medical instrument 70 comprises an elongated shaft 71(or elongate body) and an instrument base 72. The instrument base 72,also referred to as an “instrument handle” due to its intended designfor manual interaction by the physician, may generally compriserotatable drive inputs 73, e.g., receptacles, pulleys or spools, thatare designed to be mated with drive outputs 74 that extend through adrive interface on instrument driver 75 at the distal end of robotic arm76. When physically connected, latched, and/or coupled, the mated driveinputs 73 of instrument base 72 may share axes of rotation with thedrive outputs 74 in the instrument driver 75 to allow the transfer oftorque from the drive outputs 74 to the drive inputs 73. In someembodiments, the drive outputs 74 may comprise splines that are designedto mate with receptacles on the drive inputs 73.

The elongated shaft 71 is designed to be delivered through either ananatomical opening or lumen, e.g., as in endoscopy, or a minimallyinvasive incision, e.g., as in laparoscopy. The elongated shaft 71 maybe either flexible (e.g., having properties similar to an endoscope) orrigid (e.g., having properties similar to a laparoscope) or contain acustomized combination of both flexible and rigid portions. Whendesigned for laparoscopy, the distal end of a rigid elongated shaft maybe connected to an end effector extending from a jointed wrist formedfrom a clevis with at least one degree of freedom and a surgical tool ormedical instrument, such as, for example, a grasper or scissors, thatmay be actuated based on force from the tendons as the drive inputsrotate in response to torque received from the drive outputs 74 of theinstrument driver 75. When designed for endoscopy, the distal end of aflexible elongated shaft may include a steerable or controllable bendingsection that may be articulated and bent based on torque received fromthe drive outputs 74 of the instrument driver 75.

Torque from the instrument driver 75 is transmitted down the elongatedshaft 71 using tendons along the elongated shaft 71. These individualtendons, such as pull wires, may be individually anchored to individualdrive inputs 73 within the instrument handle 72. From the handle 72, thetendons are directed down one or more pull lumens along the elongatedshaft 71 and anchored at the distal portion of the elongated shaft 71,or in the wrist at the distal portion of the elongated shaft. During asurgical procedure, such as a laparoscopic, endoscopic or hybridprocedure, these tendons may be coupled to a distally mounted endeffector, such as a wrist, grasper, or scissor. Under such anarrangement, torque exerted on drive inputs 73 would transfer tension tothe tendon, thereby causing the end effector to actuate in some way. Insome embodiments, during a surgical procedure, the tendon may cause ajoint to rotate about an axis, thereby causing the end effector to movein one direction or another. Alternatively, the tendon may be connectedto one or more jaws of a grasper at the distal end of the elongatedshaft 71, where tension from the tendon causes the grasper to close.

In endoscopy, the tendons may be coupled to a bending or articulatingsection positioned along the elongated shaft 71 (e.g., at the distalend) via adhesive, control ring, or other mechanical fixation. Whenfixedly attached to the distal end of a bending section, torque exertedon the drive inputs 73 would be transmitted down the tendons, causingthe softer, bending section (sometimes referred to as the articulablesection or region) to bend or articulate. Along the non-bendingsections, it may be advantageous to spiral or helix the individual pulllumens that direct the individual tendons along (or inside) the walls ofthe endoscope shaft to balance the radial forces that result fromtension in the pull wires. The angle of the spiraling and/or spacingtherebetween may be altered or engineered for specific purposes, whereintighter spiraling exhibits lesser shaft compression under load forces,while lower amounts of spiraling results in greater shaft compressionunder load forces, but limits bending. On the other end of the spectrum,the pull lumens may be directed parallel to the longitudinal axis of theelongated shaft 71 to allow for controlled articulation in the desiredbending or articulable sections.

In endoscopy, the elongated shaft 71 houses a number of components toassist with the robotic procedure. The shaft 71 may comprise a workingchannel for deploying surgical tools (or medical instruments),irrigation, and/or aspiration to the operative region at the distal endof the shaft 71. The shaft 71 may also accommodate wires and/or opticalfibers to transfer signals to/from an optical assembly at the distaltip, which may include an optical camera. The shaft 71 may alsoaccommodate optical fibers to carry light from proximally-located lightsources, such as light emitting diodes, to the distal end of the shaft71.

At the distal end of the instrument 70, the distal tip may also comprisethe opening of a working channel for delivering tools for diagnosticand/or therapy, irrigation, and aspiration to an operative site. Thedistal tip may also include a port for a camera, such as a fiberscope ora digital camera, to capture images of an internal anatomical space.Relatedly, the distal tip may also include ports for light sources forilluminating the anatomical space when using the camera.

In the example of FIG. 16 , the drive shaft axes, and thus the driveinput axes, are orthogonal to the axis of the elongated shaft 71. Thisarrangement, however, complicates roll capabilities for the elongatedshaft 71. Rolling the elongated shaft 71 along its axis while keepingthe drive inputs 73 static results in undesirable tangling of thetendons as they extend off the drive inputs 73 and enter pull lumenswithin the elongated shaft 71. The resulting entanglement of suchtendons may disrupt any control algorithms intended to predict movementof the flexible elongated shaft 71 during an endoscopic procedure.

FIG. 17 illustrates an alternative design for an instrument driver andinstrument where the axes of the drive units are parallel to the axis ofthe elongated shaft of the instrument. As shown, a circular instrumentdriver 80 comprises four drive units with their drive outputs 81 alignedin parallel at the end of a robotic arm 82. The drive units, and theirrespective drive outputs 81, are housed in a rotational assembly 83 ofthe instrument driver 80 that is driven by one of the drive units withinthe assembly 83. In response to torque provided by the rotational driveunit, the rotational assembly 83 rotates along a circular bearing thatconnects the rotational assembly 83 to the non-rotational portion 84 ofthe instrument driver 80. Power and controls signals may be communicatedfrom the non-rotational portion 84 of the instrument driver 80 to therotational assembly 83 through electrical contacts that may bemaintained through rotation by a brushed slip ring connection (notshown). In other embodiments, the rotational assembly 83 may beresponsive to a separate drive unit that is integrated into thenon-rotatable portion 84, and thus not in parallel to the other driveunits. The rotational mechanism 83 allows the instrument driver 80 torotate the drive units, and their respective drive outputs 81, as asingle unit around an instrument driver axis 85.

Like earlier disclosed embodiments, an instrument 86 may comprise anelongated shaft portion 88 and an instrument base 87 (shown with atransparent external skin for discussion purposes) comprising aplurality of drive inputs 89 (such as receptacles, pulleys, and spools)that are configured to receive the drive outputs 81 in the instrumentdriver 80. Unlike prior disclosed embodiments, the instrument shaft 88extends from the center of the instrument base 87 with an axissubstantially parallel to the axes of the drive inputs 89, rather thanorthogonal as in the design of FIG. 16 .

When coupled to the rotational assembly 83 of the instrument driver 80,the medical instrument 86, comprising instrument base 87 and instrumentshaft 88, rotates in combination with the rotational assembly 83 aboutthe instrument driver axis 85. Since the instrument shaft 88 ispositioned at the center of instrument base 87, the instrument shaft 88is coaxial with instrument driver axis 85 when attached. Thus, rotationof the rotational assembly 83 causes the instrument shaft 88 to rotateabout its own longitudinal axis. Moreover, as the instrument base 87rotates with the instrument shaft 88, any tendons connected to the driveinputs 89 in the instrument base 87 are not tangled during rotation.Accordingly, the parallelism of the axes of the drive outputs 81, driveinputs 89, and instrument shaft 88 allows for the shaft rotation withouttangling any control tendons.

FIG. 18 illustrates an instrument having an instrument based insertionarchitecture in accordance with some embodiments. The instrument 150 canbe coupled to any of the instrument drivers discussed above. Theinstrument 150 comprises an elongated shaft 152, an end effector 162connected to the shaft 152, and a handle 170 coupled to the shaft 152.The elongated shaft 152 comprises a tubular member having a proximalportion 154 and a distal portion 156. The elongated shaft 152 comprisesone or more channels or grooves 158 along its outer surface. The grooves158 are configured to receive one or more wires or cables 180therethrough. One or more cables 180 thus run along an outer surface ofthe elongated shaft 152. In other embodiments, cables 180 can also runthrough the elongated shaft 152. Manipulation of the one or more cables180 (e.g., via an instrument driver) results in actuation of the endeffector 162.

The instrument handle 170, which may also be referred to as aninstrument base, may generally comprise an attachment interface 172having one or more mechanical inputs 174, e.g., receptacles, pulleys orspools, that are designed to be reciprocally mated with one or moretorque couplers on an attachment surface of an instrument driver.

In some embodiments, the instrument 150 comprises a series of pulleys orcables that enable the elongated shaft 152 to translate relative to thehandle 170. In other words, the instrument 150 itself comprises aninstrument-based insertion architecture that accommodates insertion ofthe instrument, thereby minimizing the reliance on a robot arm toprovide insertion of the instrument 150. In other embodiments, a roboticarm can be largely responsible for instrument insertion.

E. Controller.

Any of the robotic systems described herein can include an input deviceor controller for manipulating an instrument attached to a robotic arm.In some embodiments, the controller can be coupled (e.g.,communicatively, electronically, electrically, wirelessly and/ormechanically) with an instrument such that manipulation of thecontroller causes a corresponding manipulation of the instrument e.g.,via master slave control.

FIG. 19 is a perspective view of an embodiment of a controller 182. Inthe present embodiment, the controller 182 comprises a hybrid controllerthat can have both impedance and admittance control. In otherembodiments, the controller 182 can utilize just impedance or passivecontrol. In other embodiments, the controller 182 can utilize justadmittance control. By being a hybrid controller, the controller 182advantageously can have a lower perceived inertia while in use.

In the illustrated embodiment, the controller 182 is configured to allowmanipulation of two medical instruments, and includes two handles 184.Each of the handles 184 is connected to a gimbal 186. Each gimbal 186 isconnected to a positioning platform 188.

As shown in FIG. 19 , each positioning platform 188 includes a SCARA arm(selective compliance assembly robot arm) 198 coupled to a column 194 bya prismatic joint 196. The prismatic joints 196 are configured totranslate along the column 194 (e.g., along rails 197) to allow each ofthe handles 184 to be translated in the z-direction, providing a firstdegree of freedom. The SCARA arm 198 is configured to allow motion ofthe handle 184 in an x-y plane, providing two additional degrees offreedom.

In some embodiments, one or more load cells are positioned in thecontroller. For example, in some embodiments, a load cell (not shown) ispositioned in the body of each of the gimbals 186. By providing a loadcell, portions of the controller 182 are capable of operating underadmittance control, thereby advantageously reducing the perceivedinertia of the controller while in use. In some embodiments, thepositioning platform 188 is configured for admittance control, while thegimbal 186 is configured for impedance control. In other embodiments,the gimbal 186 is configured for admittance control, while thepositioning platform 188 is configured for impedance control.Accordingly, for some embodiments, the translational or positionaldegrees of freedom of the positioning platform 188 can rely onadmittance control, while the rotational degrees of freedom of thegimbal 186 rely on impedance control.

F. Navigation and Control.

Traditional endoscopy may involve the use of fluoroscopy (e.g., as maybe delivered through a C-arm) and other forms of radiation-based imagingmodalities to provide endoluminal guidance to an operator physician. Incontrast, the robotic systems contemplated by this disclosure canprovide for non-radiation-based navigational and localization means toreduce physician exposure to radiation and reduce the amount ofequipment within the operating room. As used herein, the term“localization” may refer to determining and/or monitoring the positionof objects in a reference coordinate system. Technologies such aspre-operative mapping, computer vision, real-time EM tracking, and robotcommand data may be used individually or in combination to achieve aradiation-free operating environment. In other cases, whereradiation-based imaging modalities are still used, the pre-operativemapping, computer vision, real-time EM tracking, and robot command datamay be used individually or in combination to improve upon theinformation obtained solely through radiation-based imaging modalities.

FIG. 20 is a block diagram illustrating a localization system 90 thatestimates a location of one or more elements of the robotic system, suchas the location of the instrument, in accordance to an exampleembodiment. The localization system 90 may be a set of one or morecomputer devices configured to execute one or more instructions. Thecomputer devices may be embodied by a processor (or processors) andcomputer-readable memory in one or more components discussed above. Byway of example and not limitation, the computer devices may be in thetower 30 shown in FIG. 1 , the cart 11 shown in FIGS. 1-4 , the bedsshown in FIGS. 5-14 , etc.

As shown in FIG. 20 , the localization system 90 may include alocalization module 95 that processes input data 91-94 to generatelocation data 96 for the distal tip of a medical instrument. Thelocation data 96 may be data or logic that represents a location and/ororientation of the distal end of the instrument relative to a frame ofreference. The frame of reference can be a frame of reference relativeto the anatomy of the patient or to a known object, such as an EM fieldgenerator (see discussion below for the EM field generator).

The various input data 91-94 are now described in greater detail.Pre-operative mapping may be accomplished through the use of thecollection of low dose CT scans. Pre-operative CT scans arereconstructed into three-dimensional images, which are visualized, e.g.as “slices” of a cutaway view of the patient's internal anatomy. Whenanalyzed in the aggregate, image-based models for anatomical cavities,spaces and structures of the patient's anatomy, such as a patient lungnetwork, may be generated. Techniques such as center-line geometry maybe determined and approximated from the CT images to develop athree-dimensional volume of the patient's anatomy, referred to as modeldata 91 (also referred to as “preoperative model data” when generatedusing only preoperative CT scans). The use of center-line geometry isdiscussed in U.S. patent application Ser. No. 14/523,760, published asU.S. Pat. Pub. No. 2015/0119637 on Apr. 30, 2015, issued as U.S. Pat.No. 9,763,741 on Sep. 19, 2017, the contents of which are hereinincorporated in its entirety. Network topological models may also bederived from the CT-images, and are particularly appropriate forbronchoscopy.

In some embodiments, the instrument may be equipped with a camera toprovide vision data (or image data) 92. The localization module 95 mayprocess the vision data to enable one or more vision-based (orimage-based) location tracking modules or features. For example, thepreoperative model data may be used in conjunction with the vision data92 to enable computer vision-based tracking of the medical instrument(e.g., an endoscope or an instrument advance through a working channelof the endoscope). For example, using the preoperative model data 91,the robotic system may generate a library of expected endoscopic imagesfrom the model based on the expected path of travel of the endoscope,each image linked to a location within the model. Intra-operatively,this library may be referenced by the robotic system in order to comparereal-time images captured at the camera (e.g., a camera at a distal endof the endoscope) to those in the image library to assist localization.

Other computer vision-based tracking techniques use feature tracking todetermine motion of the camera, and thus the endoscope. Some features ofthe localization module 95 may identify circular geometries in thepreoperative model data 91 that correspond to anatomical lumens andtrack the change of those geometries to determine which anatomical lumenwas selected, as well as the relative rotational and/or translationalmotion of the camera. Use of a topological map may further enhancevision-based algorithms or techniques.

Optical flow, another computer vision-based technique, may analyze thedisplacement and translation of image pixels in a video sequence in thevision data 92 to infer camera movement. Examples of optical flowtechniques may include motion detection, object segmentationcalculations, luminance, motion compensated encoding, stereo disparitymeasurement, etc. Through the comparison of multiple frames overmultiple iterations, movement and location of the camera (and thus theendoscope) may be determined.

The localization module 95 may use real-time EM tracking to generate areal- time location of the endoscope in a global coordinate system thatmay be registered to the patient's anatomy, represented by thepreoperative model. In EM tracking, an EM sensor (or tracker) comprisingof one or more sensor coils embedded in one or more locations andorientations in a medical instrument (e.g., an endoscopic tool) measuresthe variation in the EM field created by one or more static EM fieldgenerators positioned at a known location. The location informationdetected by the EM sensors is stored as EM data 93. The EM fieldgenerator (or transmitter), may be placed close to the patient to createa low intensity magnetic field that the embedded sensor may detect. Themagnetic field induces small currents in the sensor coils of the EMsensor, which may be analyzed to determine the distance and anglebetween the EM sensor and the EM field generator. These distances andorientations may be intra-operatively “registered” to the patientanatomy (e.g., the preoperative model) in order to determine thegeometric transformation that aligns a single location in the coordinatesystem with a position in the pre-operative model of the patient'sanatomy. Once registered, an embedded EM tracker in one or morepositions of the medical instrument (e.g., the distal tip of anendoscope) may provide real-time indications of the progression of themedical instrument through the patient's anatomy.

Robotic command and kinematics data 94 may also be used by thelocalization module 95 to provide localization data 96 for the roboticsystem. Device pitch and yaw resulting from articulation commands may bedetermined during pre-operative calibration. Intra-operatively, thesecalibration measurements may be used in combination with known insertiondepth information to estimate the position of the instrument.Alternatively, these calculations may be analyzed in combination withEM, vision, and/or topological modeling to estimate the position of themedical instrument within the network.

As FIG. 20 shows, a number of other input data can be used by thelocalization module 95. For example, although not shown in FIG. 20 , aninstrument utilizing shape-sensing fiber can provide shape data that thelocalization module 95 can use to determine the location and shape ofthe instrument.

The localization module 95 may use the input data 91-94 incombination(s). In some cases, such a combination may use aprobabilistic approach where the localization module 95 assigns aconfidence weight to the location determined from each of the input data91-94. Thus, where the EM data may not be reliable (as may be the casewhere there is EM interference) the confidence of the locationdetermined by the EM data 93 can be decrease and the localization module95 may rely more heavily on the vision data 92 and/or the roboticcommand and kinematics data 94.

As discussed above, the robotic systems discussed herein may be designedto incorporate a combination of one or more of the technologies above.The robotic system's computer-based control system, based in the tower,bed and/or cart, may store computer program instructions, for example,within a non-transitory computer-readable storage medium such as apersistent magnetic storage drive, solid state drive, or the like, that,upon execution, cause the system to receive and analyze sensor data anduser commands, generate control signals throughout the system, anddisplay the navigational and localization data, such as the position ofthe instrument within the global coordinate system, anatomical map, etc.

2. Suction Irrigator Grasper Instrument.

FIG. 21 illustrates a side view of an embodiment of a multi-functionalsurgical instrument 200. The surgical instrument 200 can include anelongate shaft 202, a handle 204, a wrist 206, and a surgical effector208. FIGS. 22A-C illustrate enlarged views of an example surgicaleffector 208 of a surgical instrument 200, such as the surgicalinstrument 200 of FIG. 21 .

FIG. 22A illustrates an enlarged perspective view of the end effector orsurgical effector 208 of the surgical instrument 200. FIG. 22Billustrates a side view of an embodiment of the surgical effector 208shown in FIG. 22A. FIG. 22C illustrates a front view of the embodimentof the surgical effector 208 shown in FIGS. 22A-22B.

As shown in FIGS. 22A-C, the surgical wrist 206 can include a proximalclevis 250 and a distal clevis 260. The term “clevis” can include anytype of connector that can support a joint, such as a pin or rollingjoint. The wrist 206 can be mechanically coupled to the surgicaleffector 208. The distal clevis 260 can be located distally in relationto the proximal clevis 250. Likewise, the surgical effector 208 can belocated distally in relation to the distal clevis 260. The distal clevis260 may be mechanically coupled to the surgical effector 208 by distaljoints 222, which will be described in more detail below. The proximalclevis 250 may be mechanically coupled to the distal clevis 260 byproximal joints 220.

FIG. 23A shows an illustration of the surgical wrist 206 with four cablesegments including a first cable segment 230, a second cable segment232, a third cable segment 234 and a fourth cable segment 236. Thesurgical effector 208 can actuate in multiple degrees of movement. Inthe illustrated embodiment, the surgical effector 208 has degrees ofmovement about a pitch axis 290 and a yaw axis 292 as will be describedin more detail below. In some embodiments, the surgical effector 208 canhave N+1 cable segments and N degrees of freedom of movement. Forexample, the surgical effector 208 can be a two degree-of-freedom wrist,pivotable around the pitch axis 290 and the yaw axis 292. In someembodiments, as shown in FIG. 23A, the surgical effector 208 cancomprise at least four cable segments 230, 232, 234, 236 to control atleast three degrees of freedom, such as, for example, pitch, yaw andgrip of the surgical effector 208.

As shown in greater detail in FIG. 23A, the wrist 206 can include fourcable segments including the first cable segment 230, the second cablesegment 232, the third cable segment 234 and the fourth cable segment236. In some embodiments, the cable segments can be portions of the samecable. For example, the first cable segment 230 and the second cablesegment 232 can be portions of the same cable. Likewise, in someembodiments, the third cable segment 234 and the fourth cable segment236 can be portions of the same cable. The cable segments 230, 232, 234,236 can extend along the elongate shaft 202, extend through the proximalclevis 250, and extend through the distal clevis 260. In someembodiments, the cables 230, 232, 234, 236 can pass through elements(e.g. distal clevis 260 and proximal clevis 250) on an axissubstantially parallel to a longitudinal axis 294 of the shaft, allowingother elements, especially those with large or limited bending radii, tooccupy said space.

Positioning the cable segments 230, 232, 234, 236 through the walls ofthe wrist 206 allows for additional components to be added to thesurgical instrument 200 without increasing the diameter of theinstrument 200. For example, a tube 270 for suction and/or irrigationmay be positioned within the working lumen of the surgical instrument200. For example, in certain embodiments, the outer diameter of thesurgical instrument 200 can be reduced to less than 6 mm, such asbetween 5 mm and 6 mm. With reference to FIGS. 26A-26D and 27A-27D, thesurgical instrument 200 described herein can also include passages 252,262 formed in the walls of the wrist 206 to direct the cable segments230, 232, 234, 236 through the surgical instrument 200. As shown inFIGS. 26A-26D and 27A-27D, the passages 252, 262 can be formed withinthe walls of the distal clevis 260 and/or the proximal clevis 250 of theinstrument 200. These passages can be used instead of pulleys, which canfurther reduce the size of the surgical instrument.

As shown in FIG. 23A, the proximal clevis 250 can have proximal passages252 and the distal clevis 260 can have distal passages 262. The proximalpassages 252 and distal passages 262 can receive the cable segments 230,232, 234, 236, as shown in FIG. 23A. Each of the cable segments 230,232, 234, 236 can be configured to engage the passages 252 and distalpassages 262, as shown in FIG. 23A. The cable segments 230, 232, 234,236 can engage at least a portion of the surgical effector 208. Thesurgical effector 208 can have effector redirect surfaces 210 configuredto engage the cable segments 230, 232, 234, 236, as shown in FIGS. 24Aand 25A-25C.

In the embodiment in FIGS. 22A-22C, the proximal clevis 250 can beconfigured to be mechanically attached to the distal end of the elongateshaft 202 (not shown). The proximal clevis 250 can include proximalpassages 252, as shown in FIGS. 23A-C and FIGS. 26A-F, that redirect thecable segments 230, 232, 234, 236 through the proximal clevis 250towards the distal clevis 260. Similarly, the distal clevis 260 cancomprise distal passages 262, as shown in FIGS. 23A-C and FIGS. 27A-F,that redirect the cable segments 230, 232, 234, 236 through the distalclevis 260 towards the surgical effector 208.

The proximal passages 252 of the proximal clevis 250 and the distalpassages 262 of the distal clevis 260 can be configured to reduce, or insome cases, prevent tangling or abrasion of the cable segments 230, 232,234, 236. The proximal passages 252 can also be configured to reduce theamount of friction between the cable segments 230, 232, 234, 236 and theproximal clevis 250. The distal passages 262 can also be configured toreduce the amount of friction between the cable segments 230, 232, 234,236 and the distal clevis 260. In some embodiments, the proximalpassages 252 and/or the distal passages 262 can form holes that extendat least partially through the walls of the proximal clevis 250 anddistal clevis 260.

As shown in FIG. 23A and FIGS. 25A and 25B, the surgical effector 208can include a first jaw half 208 a and a second jaw half 208 b. As shownin FIG. 23A, the first cable segment 230 and the second cable segment232 can be routed on a first side of the surgical effector 208 on thefirst jaw half 208 a, while the third cable segment 234 and the fourthcable segment 236 can be routed on a second side of the surgicaleffector 208 on the second jaw half 208 b. In such a configuration, thefirst cable segment 230 and the second cable segment 232 canadvantageously engage the effector redirect surfaces 210 of the firstjaw half 208 a to rotate the first jaw half 208 a about the yaw axis292. The third cable segment 234 and fourth cable segment 236 canadvantageously engage effector redirect surfaces 210 of the second jawhalf 208 b to rotate the second jaw half 208 b about the yaw axis 292.

Also shown in FIG. 23A, the first cable segment 230 and the second cablesegment 232 can be routed on a first side of the wrist 206, while thethird cable segment 234 and the fourth cable segment 236 can be routedon a second side of the wrist 206.

The first cable segment 230 and the second cable segment 232 can berouted on a first side of the distal clevis 260, while the third cablesegment 234 and the fourth cable segment 236 can be routed on a secondside of the distal clevis 260. The first cable segment 230 and thirdcable segment 234 can be routed on a first side of the proximal clevis250, while the second cable segment 232 and fourth cable segment 236 canbe routed on a second side of the proximal clevis 250.

FIG. 23B illustrates a perspective view of the surgical instrument 200of FIGS. 22A-22C, showing rotation of the surgical effector 208 about ayaw axis 292 and rotation of a surgical effector 208 about a pitch axis290. FIG. 23C illustrates a perspective view of the surgical instrumentof FIGS. 22A-22C, showing another rotation of the surgical effector 208about a yaw axis 292 and rotation of a surgical effector 208 about apitch axis 290.

In some embodiments, the yaw motion of each jaw half 208 a, 208 b of thesurgical effector 208 can be actuated by a combination of cable segmentactuations. For example, the lengthening of cable segment 230 matchedwith a shortening of cable segment 232 can cause the first jaw half 208a to rotate about the yaw axis 292 about the distal joints 222 in afirst direction. In some embodiments, the yaw motion of each half 208 a,208 b can be actuated by applying tension (such as pulling) of cablesegment 232 matched by a slackening of cable segment 230, which cancause the first jaw 208 a to rotate about the yaw axis 292 about thedistal joints 222, in a first direction. The second cable segment 232can have tension applied, such as pulling, to actuate the first jaw half208 a of the surgical effector 208 in a second direction about the yawaxis 292, where the second direction is opposite the first direction.

The second jaw half 208 b can be actuated by a combination of cablesegment actuations of the third and fourth cable segments 234, 236 in asimilar manner as the first jaw half 208 a as described above. Forexample, the third cable segment 234 can have tension applied, such aspulling, to actuate the second jaw half 208 b of the surgical effector208 in a first direction about the yaw axis 292. The fourth cablesegment 236 can have tension applied, such as pulling, to actuate thesecond jaw half 208 b of the surgical effector 208 in a second directionabout the yaw axis 292, where the second direction is opposite the firstdirection.

Each of the cable segments 230, 232, 234, 236 can be independentlyactuated. In some embodiments, each of the cable segments 230, 232, 234,236 are independent, separate cable segments that are not connected(such that none would be considered as part of the same cable). In otherembodiments, the first cable segment 230 and second cable segment 232may be considered as part of the same cable, while the third cablesegment 234 and fourth cable segment 236 may be considered as part ofthe same cable.

In some embodiments, the term “independently actuated” can mean that thecable segments 230, 232, 234, 236 (e.g., the first cable segment 230 andthe third cable segment 234) can move independently and/or at differentrates from one another. In some embodiments, the independent cablesegments move in equal but opposite amounts about the effector redirectsurfaces 210 of the surgical effector 208. In some embodiments, neitherof the cables or cable segments that are shared around effector redirectsurfaces 210 engage with or intersect with one another. In someembodiments, neither of the cables or cable segments that are sharedaround a effector redirect surface 210 are directly connected to oneanother, such as via a crimp.

The cable segments 230, 232, 234, 236 can be further configured so thatretracting or advancing a cable segment 230, 232, 234, 236 can actuatethe surgical effector 208 to move in a first degree of movement. In oneembodiment, shown in FIGS. 23A, 23B, 23C and 24 , the surgical effector208 can have three degrees of movement created by rotation of the aboutthe pitch axis 290 and the yaw axis 292, respectively, as well as theopening and closing of the first and second jaw halves 208 a, 208 b. Thesurgical effector 208 of the illustrated embodiment includes a first jawhalf 208 a and a second jaw half 208 b that are operatively connected tothe cable segments 230, 232, 234, 236 via effector redirect surfaces210.

In some embodiments, pitch motion of the surgical effector 208 can beactuated by a combination of cable segment actuations, such as an evenlengthening of the third and fourth cable segments 234, 236 matched withan even shortening of the first and second cable segments 230, 232,which can cause the distal clevis 260 to rotate about the pitch axis 290about the proximal joints 220 in a first direction. In some embodiments,pitch motion of the surgical effector 208 can be actuated by acombination of cable segment actuations, such as applying tension (suchas pulling) of cable segments 230, 232, matched with an even slackeningof cable segments 234, 236, which can cause the distal clevis 260 torotate about the pitch axis 290 about the proximal joints 220, in afirst direction.

Similarly, pitch motion of the surgical effector 208 can be actuated bya combination of cable segment actuations, such as an even lengtheningof cable segments 230, 232 matched with an even shortening of cablesegments 234, 236, which can cause the distal clevis 260 to rotate aboutthe pitch axis 290 about the proximal joints 220 in a second direction.In some embodiments, pitch motion of the surgical effector 208 can beactuated by a combination of cable segment actuations, such as applyingtension (such as pulling) of cable segments 234, 236 matched with aneven slackening of cable segments 230, 232, which can cause the distalclevis 260 to rotate about the pitch axis 290 about the proximal joints220, in a second direction.

FIGS. 22A-C and FIG. 23A illustrate the surgical effector 208 in anexample “neutral” state, i.e., the first yaw angle 282, the second yawangle 284, and the pitch angle 296 (shown in FIG. 23C) are not offsetfrom the central axis 294, with no cable segments being advanced orretracted. The first yaw angle 282 can be manipulated byadvancing/retracting the first cable segment 230 andretracting/advancing the second cable segment 232.

FIG. 23C illustrates the two jaw halves 208 a and 208 b of the surgicaleffector 208 rotated at the first yaw angle 282 and the second yaw angle284 about the yaw axis 292. FIGS. 23B and 23C demonstrate the potentialyaw and pitch movement of the surgical effector 208 in accordance withsome embodiments.

FIGS. 23B and 23C illustrate the two jaw halves 208 a and 208 b of thesurgical effector 208 rotated at the first yaw angle 282 and the secondyaw angle 284 about the yaw axis 292. As shown in FIGS. 23B, the two jawhalves 208 a and 208 b of the surgical effector 208 can be rotated aboutthe yaw axis 292 at the distal joint 222 together, such that they can berotated in the same direction. As shown in FIG. 23C, the two jaw halves208 a, 208 b of the surgical effector 208 can be rotated about the yawaxis 292 at the distal joints 222 independently, such that the two jawhalves 208 a, 208 b can be rotated away from each other in oppositedirections.

Although the cable segments 230, 232, 234, 236 are not shown in FIGS.23B and 23C, advancing the first cable 230 and/or retracting the secondcable 232 that engages with the effector redirect surfaces 210 of thefirst jaw half 208 a causes the first jaw half 208 a to rotate about theyaw axis 292 such that the first yaw angle 282 increases. On the otherhand, retracting the first cable segment 230 and/or advancing the secondcable segment 232 that engages with the effector redirect surfaces 210of the first jaw half 208 a causes the first jaw half 208 a to rotateabout the yaw axis 292 such that the first yaw angle 282 decreases.

Similarly, the second yaw angle 284 can be manipulated byadvancing/retracting the third cable 234 and retracting/advancing thefourth cable 236. Advancing the third cable 234 and/or retracting thefourth cable 236 that engages with the effector redirect surfaces 210 ofthe second jaw half 208 b causes the second jaw half 208 b to rotateabout the yaw axis 292 such that the second yaw angle 284 increases. Onthe other hand, retracting the third cable 234 and/or advancing thefourth cable 236 that engages with the effector redirect surfaces 210 ofthe second jaw half 208 b causes the second jaw half 208 b to rotateabout the yaw axis 292 such that the second yaw angle 284 decreases.

FIGS. 23B and 23C illustrate the distal clevis 260 of the surgicaleffector 208 rotated at the pitch angle 296 about the pitch axis 290 atthe proximal joints 220.

Although the cable segments 230, 232, 234, 236 are not shown in FIGS.23B and 23C, the pitch angle 296 of the surgical effector 208 can bemanipulated by retracting/advancing the first cable segment 230 and thesecond cable segment 232 and advancing/retracting the third cablesegment 234 and the fourth cable segment 236. On the other hand,advancing both the first cable segment 230 and the second cable segment232 and retracting both the third cable segment 234 and the fourth cablesegment 236 can cause the surgical effector 208 to rotate about thepitch axis 290 such that the pitch angle 296 decreases.

The above description is a configuration controlling the degrees offreedom in which each movement is asynchronous and controlledindependently. However, in certain robotic surgical operations thedegrees of freedom are changed simultaneously. One skilled in the artwill note that simultaneous motion about the three controllable degreesof freedom can be accomplished by a more complex control scheme foradvancing and retracting the four cable segments 230, 232, 234, 236. Insome embodiments, the four cable segments 230, 232, 234, 236 are formedof a metal, while in other embodiments, the four cable segments 230,232, 234, 236 are formed of a non-metal. In one embodiment, this controlscheme involves a computer-based control system that stores computerprogram instructions of a master device configured to interpret themotions of the user into corresponding actions of the surgical effector208 at the surgical site. The computer program may be configured tomeasure the electric load required to rotate the input controllers tocompute the length and/or movement of the cable segments. The computerprogram may be further configured to compensate for changes in cablesegment elasticity, such as if the cables are a polymer, byincreasing/decreasing the amount of rotation needed for the inputcontrollers to change the length of a cable segment. The tension may beadjusted by increasing or decreasing the rotation of all the inputcontrollers in coordination. The tension can be increased bysimultaneously increasing rotation, and the tension can be decreased bysimultaneously decreasing rotation. The computer program may be furtherconfigured to maintain a minimum level of tension in the cables. If thetension in any of the cables is sensed to drop below a minimum tensionthreshold, then the computer program may increase rotation of all inputcontrollers in coordination until the cable tension in all cables isabove the minimum tension threshold. If the tension in all of the cablesis sensed to rise above a maximum tension threshold, then the computerprogram may decrease rotation of all input controllers in coordinationuntil the cable tension in any of the cables is below the maximumtension threshold. The computer program may be further configured torecognize the grip strength of the operator based on the load of themotors actuating the input controllers coupled to the cable segments,particularly in a situation where the working members are holding on toan object or are pressed together. More generally, the computer programmay be further configured to control the translation and rotation of thesurgical instrument via the robotic arm, which in certain embodimentscan include an instrument driver 75 with drive outputs 74 as describedabove with reference to FIG. 16 . Torque received from the drive outputs74 of the instrument driver 75 can be used to separately and/orindependently actuate cable segments 230, 232, 234, 236. In certainembodiments, each of the drive outputs 74 can be used to actuate asingle cable segment.

A. Suction Irrigator Grasper.

FIG. 24A illustrates a perspective view of the surgical effector 208,showing rotation of two jaw halves 208 a, 208 b about a yaw axis 292.FIG. 25A illustrates a perspective view of a first jaw half 208 a of thesurgical effector 208. FIG. 25B illustrates a perspective view of asecond jaw half 208 b of the surgical effector 208. The second jaw half208 b can be a mirror image of the first jaw half 208 a.

The instrument 200 can further include a tube 270, as shown in FIGS.22A-C, 23A-C, 24A and 25C. The tube 270 extends at least partiallybetween the first jaw half 208 a and the second jaw half 208 b. The tube270 may extend through the elongate shaft 202, through the proximalclevis 250, through the distal clevis 240, and/or at least partiallythrough the surgical effector 208. In certain embodiments, the outerdiameter of the tube 270 can be than less than 6 mm, such as between 4mm and 5 mm. The tube 270 may be in fluid communication with anirrigation and fluid source. The tube 270 may help form a suction and/orirrigation path through the middle of the instrument 200.

FIG. 24B illustrates a side view of the surgical instrument of FIG. 24A,with the entire shaft and suction/irrigation lines shown. From thisview, one can see how the tube 270 is in fluid communication with both aliquid/irrigation line 271 and a suction line 273 at its proximal mostend. A pump 275 can couple the liquid/irrigation line 271 to a source ofliquid that may be in a tank 277 and a suction line 273 to an outputtank. In addition, from this view, one can see a cross-section 205 of aportion of the handle 204, which shows one or more inputs thatadvantageously enable robotic control of the irrigation and suctioncapabilities of the tube 270. In the present embodiment, the handle 204includes an input 73 that can be controlled by a drive mechanism 146A(as shown in FIG. 14 ). The input 73 is capable of clockwise andcounter-clockwise rotation (illustrated by the arrow in 205) andoperably coupled to a capstan that controls whether theliquid/irrigation line 271 or the suction line 273 is operable. In someembodiments, rotation of the capstan associated with the input 73 in afirst direction causes the liquid/irrigation line 271 to be compressed(e.g,. via a pinch valve), thereby enabling suction to take place.Likewise, rotation of the capstan in a second direction causes thesuction line 273 to be cut off (e.g., via a pinch valve), therebyenabling irrigation to take place. In other words, in some embodiments,a single input 73 of the handle 204 can advantageously control at leasttwo functions—irrigation and suction—robotically. While the presentembodiment pertains to robotic control of the irrigation and suctioncapabilities of the tube 270, in some embodiments, the instrument canalso be detached from a drive mechanism of a robotic arm and usedmanually.

The tube 270 may have a proximal end (not shown) and a distal end 288.the tube 270 may have a proximal end that terminates at the proximalclevis 250. As best seen in FIG. 24A, the distal end 288 of the tube 270may extend distally relative to the distal clevis 260 and may extend atleast partially through the surgical effector 208. The tube 270 can besecured to the wrist 206 at various points. In some embodiments, thetube 270 may be secured to the distal clevis 260 and/or the proximalclevis 250. In some embodiments, the distal end 288 of the tube 270 mayalso be secured to the wrist 206. In other embodiments, the distal end288 of the tube 270 can remain free and loose. The proximal end (notshown) of the tube 270 may be in fluid communication with a suctionand/or irrigation source. In some embodiments, the tube may be between 3and 7 millimeters in length, such as between 4 and 6 millimeters inlength.

As shown in FIGS. 22A-C and 23A-B, the first and second jaw halves 208a, 208 b can be in a closed position where the two jaw halves 208 a, 208b are positioned closely together. The jaw halves 208 a, 208 b may forma passage 298 when in the closed position. The surgical effector 208 canform a nozzle or passage 298. The first and second jaw halves 208 a, 208b need not be completely closed to form a passage 298 in fluidcommunication with the tube 270.

The tube 270 may have an outlet 286 on the distal end 288 in fluidcommunication with a passage or lumen 298 formed by an interior of thefirst and second jaw halves 208 a, 208 b. The tube 270 may act as asuction irrigation lumen when the first and second jaw halves 208 a, 208b are in the open position, as shown in FIG. 24A and FIG. 23C, and inthe closed position, as shown FIGS. 22A-C and FIG. 23B.

Each of the jaw half 208 a, 208 b may include a series of holes 212 toassist with suction and/or irrigation. The holes 212 can prevent orinhibit the passage 298 formed by the first and second jaw halves 208 a,208 b from forming a complete vacuum during suctioning. The advantage isthat the holes 212 may prevent tissue from being sucked in, such thatthe tissue will not be entirely sucked through the tube 270 incommunication with the suction source.

The tube 270 may be made of various materials. The tube 270 may beflexible or rigid. In some embodiments, the tube 270 may beindependently articulable and in some embodiments can be coupled to oneor more control cables. In other embodiments, the tube 270 may not beindependently articulable, such that the tube 270 follows thearticulation of the wrist 206 and/or surgical effector 208. For example,as shown in FIGS. 23B and 23C, as the surgical effector 208, the distalclevis 260, and/or the proximal clevis 250 may bend or rotate, the tube270 may bend to follow the direction of the surgical effector 208, thedistal clevis 260, and/or the proximal clevis 250. In some embodiments,some portions of the tube 270 may be pinched by the surgical effector208.

The surgical effector 208 can also act as a grasper or gripper. Aspreviously discussed, the first and second jaw halves 208 a, 208 b mayrotate towards each other or away from each other, between the openedand closed position, or may be moved or rotated together in the samedirection. The first and second jaw halves 208 a, 208 b may be rotated,as described previously, between the open position, as shown in FIG. 23Cand 24A, and the closed position, as shown in FIGS. 22A-C and FIG. 23B.As shown in FIGS. 23C and 24A, the first and second jaw halves 208 a,208 b can be in an open position where the distal ends of the two jawhalves 208 a, 208 b are separated from each other or are positioned awayfrom each other. The first and second jaw halves 208 a, 208 b in theopen position may be positioned around tissue to receive tissue within apatient. The first and second jaw halves 208 a, 208 b may be rotatedabout the yaw axis 292 in a closed position where the first and secondjaw halves 208 a, 208 b are configured to clamp tissue to grasp or griptissue within a patient. The first and second jaw halves 208 a, 208 bneed not be completely closed to grip the tissue, when tissue ispositioned between two jaw halves 208 a, 208 b.

As best shown in FIGS. 24A, and 25A-B, each of the first and second jawhalves 208 a, 208 b may have ridges or teeth 214 positioned on aninterior face of the first and second jaw halves 208 a, 208 b. The teeth214 may be capable of complementary engagement. For example, the firstand second jaw halves 208 a, 208 b may have teeth 214 that interdigitateor intermesh with each other. The structure and complementary engagementof the teeth 214 may minimize the profile of the teeth 214 and/or thejaw halves 208 a, 208 b. The teeth 214 may serve to easily grip thetissue within a patient. In some embodiments, the teeth 214 arepyramidal, saw tooth, or other structures. Furthermore, the teeth 214may be intermeshed with one another such that the first and second jawhalves 208 a, 208 b may form a nozzle for the suction and irrigation, asdescribed previously.

FIGS. 25A and 25B illustrate the first jaw half 208 a of the surgicaleffector 208. The second half 208 b may be a mirror image of the firstjaw half 208 a. FIG. 25C illustrates a cross sectional view ofconnection of a surgical effector 208 and distal clevis 260 of FIGS.22A-24A at the distal joints 222 a, 222 b.

The proximal end of each jaw half 208 a, 208 b 208 a, 208 b may have apin 228 a on one side and an annular pin 226 on a second side. Each ofthe first jaw and the second jaw half 208 a, 208 b may have a pin 228 a,228 b to allow pivoting about a yaw axis 292. Each of the first jaw andthe second jaw halves 208 a, 208 b may have an annular pin 226 a, 226 b,which may each have a hole configured to receive the pin 228 a, 228 b ofthe other jaw half 208 a, 208 b. For example, the first pin 228 a of thefirst jaw half 208 a may be inserted into and extend through an openingof the second annular pin 226 b of the second jaw half 208 b. Similarly,the second pin 228 b of the second jaw half 208 may be inserted into andextend through the first annular pin 226 a of the first jaw half 208 a.

In some embodiments, the annular pins 226 a, 226 b of the jaw halves 208a, 208 b may include holes or openings through a distal wall of the jawhalves 208 a, 208 b. The annular pins 226 a, 226 b of the jaw halves 208a, 208 b may be shaped and configured to receive the pins 228 a, 228 bof the jaw halves 208 a, 208 b. The first jaw and the second jaw 208 a,208 b interlock with each other to form pivot pin joints 218 a, 218 bpositioned on the both sides of the surgical effector 208. The pivot pinstructure couples the first jaw 208 a and the second jaw 208 b.

B. Distal Joints and Distal Clevis.

As shown in FIGS. 22A-24A, the distal joints 222 may be formed by theintersection or connection of the surgical effector 208 and distalclevis 260. The distal joints 222 may be positioned on the sides of theinstrument 200. The distal clevis 260 forms in part distal joints 222about which the first and second jaw halves 208 a, 208 b can rotate.Similarly, the proximal clevis forms in part proximal joints 220 aboutwhich the wrist 206 can rotate with respect to the elongate shaft 202,which will be discussed more below. The distal joints 222 may be adifferent type of joint from the proximal joints 220, which will also bediscussed more below. For example, the distal joints 222 may be pinjoints and the proximal joints 220 may be rolling joints. By providingdifferent types of joints, the instrument can be provided with differentadvantages along its length. For example, as discussed below, the distaljoints 222 are designed as pin joints that can provide additional spacefor the inner tube 270 at a distal region of the instrument.

FIG. 26A shows a top/distal face perspective view of an embodiment ofthe distal clevis 260. FIG. 26B illustrates the distal face of thedistal clevis 260. FIG. 26C illustrates the bottom/proximal face,perspective view of the distal clevis 260. FIG. 26D illustrates theproximal face of the distal clevis 260. FIG. 26E illustrates a side viewof the distal clevis 260. FIG. 26F illustrates a side view of the distalclevis 260. As best seen in FIGS. 26A-F, the distal clevis 260 caninclude two distal arms 274 a, 274 b and distal passages 262. The twodistal arms 274 a, 274 b can extend distally from side portions of thedistal clevis 260 towards the surgical effector 208. Each arm 274 mayinclude distal recesses 264 a, 264 b on the upper or distal surfaces ofeach distal arm 274 a, 274 b. The distal clevis 260 may have distalrecesses 264 a, 264 b formed on the upper or distal surfaces of thedistal clevis 260. The distal recesses 264 a, 264 b may be curvedsurfaces, openings, or recesses configured to receive pivot pin joints218 a, 218 b, which are formed by the interlocked jaw halves 208 a, 208b of the surgical effector 208.

The pivot pin joints 218 a, 218 b of the surgical effector 208 may bepositioned within or on the distal recesses 264 a, 264 b of the distalclevis 260 to form distal joints 222 on either side of the instrument200. The distal recesses 264 a, 264 b may be curved surfaces to supportat least one pivot axis, such as the yaw axis 292.

The distal recesses 264 a, 264 b may be cup-shaped or u-shaped. Thedistal recesses 264 a, 264 b may be openings shaped to receive the pivotpin joints 218 a, 218 b of the surgical effector 208, as describedpreviously. The distal recesses 264 a, 264 b may be configured to definea rotation axis at the distal joints 222. In some embodiments, therotation axis associated with the distal clevis 260 and the distaljoints 222 can be a yaw axis 292, as shown in FIGS. 23A-B and FIGS.24A-25B.

As shown in FIGS. 24A and 25C, the proximal joints 220 may be partialpin joints. The pivot pin joints 218 a, 218 b may rest on or within thedistal recesses 264 a, 264 b to form proximal joints 220. Each side ofthe instrument 200 may therefore have nesting joints or coaxial jointswhere the pin 228 is received by the annular pin 226 to form a pivot pinjoint 218, which in turn acts as pin received by the distal recesses 264a, 264 b to form a proximal joint 220. As shown in FIG. 25C, the firstpin 228 a of the first jaw half 208 a is received by the annular pin 226b of the second jaw half 208 b to form a first pivot pin joint 218 a,which in turn acts as a pin that is received by the distal recess 264 aof the distal clevis 260. The first pin 228 a of the first jaw half 208a received by the second annular pin 226 b of the second jaw half 208 bmay be the a pivot pin that is pivotably supported within the distalrecess 264 a, which may be a cup shaped opening. Similarly, the secondpin 228 b of the second jaw half 208 b received by the annular pin 226 aof the first jaw half 208 a that is pivotably supported within thedistal recess 264 b, which may be a cup shaped opening.

In order to maintain the jaw halves 208 a, 208 b of the surgicaleffector 208 on the distal recesses 264 a, 264 b, tension in the cablesegments (not shown in FIG. 24A) attached to the surgical effectorredirect surfaces 210 on the jaw halves 208 a, 208 b help to hold thejaw halves 208 a, 208 b in the distal recesses 264 a, 264 b. The jawhalves 208 a, 208 b are attached to the distal clevis 260 in this mannerso that the jaw halves 208 a, 208 b are supported on both sides of thedistal clevis 260 while also keeping the center of the instrument 200open for the flexible irrigation suction tube 270.

By allowing the jaw halves 208 a, 208 b to reside on the distal recesses264 a, 264 b, this helps to conserve internal space and volume, as thedistal clevis 260 does not need to go on the outside of the pivot pinjoints 218 a, 218 b (as shown in FIG. 25C). This advantageously helps toprovide internal space for the tube 270, which can have an outerdiameter less than 6 mm, such as 4 mm to 5 mm. This configuration allowsthe cable segments to operate towards the outer diameter of theinstrument 200 and allows the center opening 272 of the distal clevis260 to remain clear and open for the tube 270.

With continued reference to FIGS. 26A-F, the distal clevis 260 caninclude two proximal arms 276 c, 276 d. The two proximal arms 276 c, 276d can extend proximally from front and back portions of the distalclevis 260 towards the proximal clevis (not shown). Each proximal arm276 c, 276 d may include proximal surfaces 268 c, 268 d on the bottom orproximal end of each proximal arm 276 c, 276 d. The distal clevis 260may have proximal surfaces 268 c, 268 d formed on the bottom or proximalend of the distal clevis 260. The proximal surfaces 268 c, 268 d may bea curved surface, a rolling surface, an opening, or recess. The proximalsurfaces 268 c, 268 d may be configured to engage with the proximalclevis 250.

The proximal surfaces 268 c, 268 d may be configured toenable a rotationaxis at the proximal joints 220. In some embodiments, the rotation axisassociated with the proximal clevis 250 and the distal clevis 260 can bethe pitch axis 290, as shown in FIGS. 23A-B and FIGS. 24A-25B.

The distal clevis 260 may be open or hollow with a central opening 272that may be positioned and configured such that an elongate rod or tube270 can be inserted into the opening 272.

As discussed previously and as shown in FIG. 23A, the distal passages262 may receive cables 230, 232, 234, 236. As shown in FIG. 23A, thecable segments 230, 232, 234, 236 extend through the distal clevis 260toward the proximal clevis 250.

As shown in FIGS. 26A-F, the distal passages 262 may be positionedwithin the walls of the distal clevis 260, which allows a space for theopening 272. The distal passages 262 can include one or more surfacesextending about or around the opening 272 extending through a bottomportion or proximal end of the distal clevis 260, as shown in FIGS.26C-26D. In some embodiments, the distal passages 262 are part of one ormore surfaces that form a perimeter of the opening 272 of the distalclevis 260. The distal passages 262 can be angled, curved or sloped suchthat they can reduce friction between the cable segments (not shown inFIGS. 26A-F) and the distal clevis 260 when the cable segments areretracted or advanced to actuate the surgical effector 208 as describedabove. In some embodiments, the distal passages 262 are configured toincrease cable life by maximizing a radius of curvature. The distalpassages 262 can also be configured to prevent the cable segments fromtangling or twisting. In some embodiments, the distal passages 262 cancomprise of at least one moveable component such as a rotatable ball orsurface configured to engage the cable segments. In some embodiments,the cable segments can be configured to engage at least a portion of thedistal passages 262. In some embodiments, the cable segments can beconfigured to engage the entire portion of distal passages 262. In someembodiments, the distal passages 262 of the distal clevis 260 may becoated with a material to reduce friction between the distal passages262 and the cable segments. As shown in FIGS. 26A-F, the distal passages262 may extend through the distal clevis 260, from the distal end to theproximal end of the distal clevis 260.

As previously discussed, FIG. 23A illustrates an embodiment of aconfiguration of the cable segments 230, 232, 234, 236 after extendingthrough the distal clevis 260 and the distal passages 262. Afterextending through the distal passages 262, the cable segments extendaround the effector redirect surfaces 210 of the surgical effector 208.In some embodiments, the cable segments actively engage at least aportion of a plurality of grooves 216 of the surgical effector surfaces210, as shown in FIG. 23A.

In some embodiments, the cable segments actively engage the entireportion of the plurality of grooves 216 of the surgical effectorsurfaces 210. As shown in FIGS. 23A, 24A, and 25A-B, each of theplurality of grooves 216 of the surgical effector surfaces 210 can beconfigured to engage two cable segments. For example, in the embodimentshown in FIG. 23A, the first cable segment 230 and the second cablesegment 232 engage the surgical effector surfaces 210 of the first jaw208 a, while the third cable segment 234 and the fourth cable segment236 engage the surgical effector surfaces 210 of the second jaw 208 b.In some embodiments, the cable segments 230, 232, 234, 236 can beconfigured such that they do not intersect one another.

The cable segments 230, 232, 234, 236 can be further configured so thatretracting or advancing a cable segment extending about a first side ofthe first jaw half 208 a operatively coupled to the first jaw half 208 aactuates the first jaw half 208 a in a first direction of movement, andadvancing or retracting a second cable segment extending about a secondside of the first jaw half 208 b actuates the first jaw half 208 a in asecond direction of movement. The cable segments 230, 232, 234, 236 canbe further configured to engage with the second jaw half 208 b andactuate the second jaw half 208 b in a similar manner as the first jawhalf 208 a. In some embodiments, the first jaw half 208 a may beactuated by the first cable segment 230 and the second cable segment232. In some embodiments, the second jaw half 208 b may be actuated bythe third cable segment 234 and the fourth cable segment 236.

C. Proximal Joints and Proximal Clevis.

FIG. 27A illustrates a distal, perspective view of the proximal clevisof a wrist of a surgical instrument. FIG. 27B illustrates a distal viewof the proximal clevis 250. FIG. 27C illustrates a proximal, perspectiveview of the proximal clevis 250. FIG. 27D illustrates a bottom view ofthe proximal clevis 250. FIG. 27E illustrates a side view of theproximal clevis 250. FIG. 27F illustrates a front view of the proximalclevis 250. As discussed previously, the proximal clevis forms in partproximal joints 220 about which the wrist 206 can pivot with respect tothe elongate shaft 202, which will be discussed more below.

The proximal clevis 250 can include of two distal arms 254 c, 254 d. Thetwo distal arms 254 c, 254 d can extend distally from front and backportions of the proximal clevis 250 towards the distal clevis (notshown). Each distal arm 254 c, 254 d may include distal recesses 264 a,264 b on the upper or distal surfaces of each distal arm 254 c, 254 d.The distal arms 254 c, 254 d can extend distally from the front and backportions of the proximal clevis 250 towards the distal clevis (notshown). The distal arms 254 c, 254 d may align with the proximal arms268 c, 268 d of the distal clevis 260.

The proximal clevis 250 may have distal surfaces 258 c, 258 d formed onthe upper or distal surfaces of the proximal clevis 250. The distalsurfaces 258 c, 258 d may be a curved surface, rolling surface, or aprotrusion configured to engage with the proximal surfaces 268 c, 268 dof the distal clevis 260. The distal surfaces 258 c, 258 d may beconfigured to engage with the distal clevis 260.

The distal surfaces 258 c, 258 d may be configured to enable a rotationaxis at the proximal joints 220. In some embodiments, the rotation axisassociated with the proximal clevis 250 and the distal clevis 260 can bea pitch axis 290, as shown in FIGS. 23A-B and FIGS. 24A-25B.

The proximal clevis 250 may be open or hollow with a central opening 278that may be positioned and configured such that an elongate rod or tube270 can be inserted into the opening 278.

As discussed previously and as shown in FIG. 23A, the proximal passages252 may receive cables 230, 232, 234, 236. As shown in FIG. 23A, thecable segments 230, 232, 234, 236 extend through the distal clevis 260toward the proximal clevis 250.

As shown in FIGS. 27A-F, the proximal passages 252 may be positionedwithin the walls of the proximal clevis 250, which allows a space forthe opening 278. The proximal passages 252 can include one or moresurfaces extending about or around the opening 278 extending through abottom portion or proximal end of the proximal clevis 250, as shown inFIGS. 27C-27D. In some embodiments, the proximal passages 252 are partof one or more surfaces that form a perimeter of the opening 278 of theproximal clevis 250. The proximal passages 252 can be angled, curved orsloped such that they can reduce friction between the cable segments andthe proximal clevis 250 when the cable segments are retracted oradvanced to actuate the surgical effector 208 as described above. Insome embodiments, the proximal passages 252 are configured to increasecable life by maximizing a radius of curvature. The proximal passages252 can also be configured to prevent the cable segments from tanglingor twisting. In some embodiments, the proximal passages 252 can includeof at least one moveable component such as a rotatable ball or surfaceconfigured to engage the cable segments (not shown). In someembodiments, the cable segments can be configured to engage at least aportion of the proximal passages 252. In some embodiments, the cablesegments can be configured to engage the entire portion of proximalpassages 252. In some embodiments, the proximal passages 252 of theproximal clevis 250 may be coated with a material to reduce frictionbetween the proximal passages 252 and the cable segments. As shown inFIG. 25B, the proximal passages 252 may extend through the proximalclevis 250, from the distal end to the proximal end of the proximalclevis 250.

As shown in FIGS. 22A-24A, the proximal joints 220 may be formed by theintersection or connection of the distal clevis 260 and the proximalclevis 250. The proximal joints 220 may be positioned on the front andback of the instrument 200. The proximal joints 220 may be formedbetween the proximal clevis 250 and the distal clevis 260.

In some embodiments, the proximal joints 220 may be rolling joints orcycloidal joints that allows the cable segments to operate towards theouter diameter of the instrument 200 and allows the center opening 272of the distal clevis 260 and the center opening 278 of the proximalclevis 250 of the instrument 200 to be open for the tube 270.

The proximal joints 220 may be formed by the intersection or connectionof the proximal end of the distal clevis 260 with the distal end of theproximal clevis 250.

As previously discussed, the distal clevis 260 may have proximalsurfaces 268 c, 268 d formed on the bottom or proximal end of the distalclevis 260. The proximal surfaces 268 c, 268 d may be a curved surface,a rolling surface, an opening, or a recess configured to receive orengage with the proximal clevis 250.

As previously discussed, the proximal clevis 250 may have distalsurfaces 258 c, 258 d formed on the top or distal end of the proximalclevis 250. The distal surfaces 258 c, 258 d may be a curved surface, arolling surface, or a protrusion configured to be inserted within orengage with the distal clevis 260.

As shown in FIGS. 23B-C, the proximal joints 220 allow the distal clevis260 to rotate about the pitch axis 290 relative to the proximal clevis250. The proximal joints 220 allow the distal clevis 260 and/or thewrist 206 to pivot with respect to the proximal clevis 250 and/or theelongate shaft 202.

As described previously and shown in FIG. 23A, the cable segments 230,232, 234, 236 can be configured to extend through the proximal clevis250. As described previously, the cable segments 230, 232, 234, 236 canbe configured to actively engage at least a portion of a plurality ofgrooves 216 of the surgical effector surfaces 210.

D. Example Method of Use.

During laparoscopic surgery, surgeons may need a suction/irrigator toolto flush a liquid and/or remove pooling liquid at a surgical site. Oftentimes, multiple tools (e.g., a grasper and a separate suction/irrigator)may be needed. But the use of multiple tools can be undesired due tospace and time constraints, the need for an additional incision, theneed for an additional assistant, and the cost of an additional tool. Asdescribed previously, the surgical instrument 200 provides amulti-functional instrument that can serve as both a grasper and asuction/irrigator. Accordingly, in some embodiments, it can serve atleast three functions.

The surgical instrument 200 described above provides a number ofadvantages over other devices, including allowing a surgeon to quicklyreach a surgical site to provide irrigation or clear it of poolingblood. In addition, when compared to manual procedures, therobotically-controlled, multi-functional surgical instrument 200 canreduce the need of having an assistant use a manual suction irrigator inaddition to a grasper. Furthermore, the use of therobotically-controlled multi-functional surgical instrument 200 reducesthe need for tool exchange.

FIG. 28 illustrates a method of use of a surgical instrument 200 at asurgical site 320. The surgical instrument 200 may include inserting adistal end of the surgical instrument 200 into a patient, using thesurgical instrument 200 to grip tissue within the patient, and using thesurgical instrument 200 to perform a suction and/or irrigation procedurewithin the patient.

Another exemplary method of using an surgical instrument 200 describedabove includes:

a) Forming a first incision 302, a second incision 304, and a thirdincision 306;

b) Inserting a first cannula 312 through the first incision 302, asecond cannula 314 through the second incision 304 and a third cannula316 through the third incision 306;

c) Inserting a first instrument 300 through the first cannula 312,wherein the first instrument 300 includes a grasper (e.g., a bipolargrasper) for holding tissue at a surgical site 320;

d) Inserting a second instrument 400 through the second cannula 314,wherein the second instrument 400 includes a cutting instrument (e.g., amonopolar curved shear) for performing a procedure at the surgical site320;

e) Inserting a third instrument 200 through the third cannula 316,wherein the third instrument 200 includes a surgical instrument 200 asdescribed above (e.g., a suction irrigation grasper) for holdingadjacent tissue 322 adjacent to the surgical site 320;

f) Detecting a need for suction or irrigation at the surgical site 320;

g) Maneuvering the first instrument 300 such that it holds the adjacenttissue 322 adjacent to the surgical site 320 (denoted by the perforatedarrow extending from the first instrument 300 to the adjacent tissue322);

h) Maneuvering the third surgical instrument 200 such that it performs asuction or irrigation procedure at the surgical site 320 (denoted by theperforated arrow extending from the third instrument 200 to the surgicalsite 320), wherein each of the first instrument 300, second instrument400 and third instrument 200 remain docked to their respective cannulas.

Note that the method described above provides a number of advantages.First, as the instruments can be robotically controlled, there is alesser need for an additional assistant to control a manual suction orirrigation instrument, which may require an additional port. Second, asthe instruments all remain docked to their respective cannulas, there isno need to undock and swap instruments, which can be time consuming.During an operation, it can be crucial to get to a site of internalbleeding as quickly as possible (e.g., for vacuuming). The use of amulti-functional instrument 200 such as the suction irrigation grasperhelps to get to such a site rapidly and with ease, without needing toswap tools.

3. Implementing Systems and Terminology.

Implementations disclosed herein provide system, methods, and apparatusfor robotically-enabled medical systems. Various implementationsdescribed herein include robotically-enabled medical systems with awrist comprising one or more pulleys shared by cable segments.

It should be noted that the terms “couple,” “coupling,” “coupled” orother variations of the word couple as used herein may indicate eitheran indirect connection or a direct connection. For example, if a firstcomponent is “coupled” to a second component, the first component may beeither indirectly connected to the second component via anothercomponent or directly connected to the second component.

The robotic motion actuation functions described herein may be stored asone or more instructions on a processor-readable or computer-readablemedium. The term “computer-readable medium” refers to any availablemedium that can be accessed by a computer or processor. By way ofexample, and not limitation, such a medium may comprise random accessmemory (RAM), read-only memory (ROM), electrically erasable programmableread-only memory (EEPROM), flash memory, compact disc read-only memory(CD-ROM) or other optical disk storage, magnetic disk storage or othermagnetic storage devices, or any other medium that can be used to storedesired program code in the form of instructions or data structures andthat can be accessed by a computer. It should be noted that acomputer-readable medium may be tangible and non-transitory. As usedherein, the term “code” may refer to software, instructions, code ordata that is/are executable by a computing device or processor.

The methods disclosed herein comprise one or more steps or actions forachieving the described method. The method steps and/or actions may beinterchanged with one another without departing from the scope of theclaims. In other words, unless a specific order of steps or actions isrequired for proper operation of the method that is being described, theorder and/or use of specific steps and/or actions may be modifiedwithout departing from the scope of the claims.

As used herein, the term “plurality” denotes two or more. For example, aplurality of components indicates two or more components. The term“determining” encompasses a wide variety of actions and, therefore,“determining” can include calculating, computing, processing, deriving,investigating, looking up (e.g., looking up in a table, a database oranother data structure), ascertaining and the like. Also, “determining”can include receiving (e.g., receiving information), accessing (e.g.,accessing data in a memory) and the like. Also, “determining” caninclude resolving, selecting, choosing, establishing and the like.

The phrase “based on” does not mean “based only on,” unless expresslyspecified otherwise. In other words, the phrase “based on” describesboth “based only on” and “based at least on.”

The previous description of the disclosed implementations is provided toenable any person skilled in the art to make or use the presentinvention. Various modifications to these implementations will bereadily apparent to those skilled in the art, and the generic principlesdefined herein may be applied to other implementations without departingfrom the scope of the invention. For example, it will be appreciatedthat one of ordinary skill in the art will be able to employ a numbercorresponding alternative and equivalent structural details, such asequivalent ways of fastening, mounting, coupling, or engaging toolcomponents, equivalent mechanisms for producing particular actuationmotions, and equivalent mechanisms for delivering electrical energy.Thus, the present invention is not intended to be limited to theimplementations shown herein but is to be accorded the widest scopeconsistent with the principles and novel features disclosed herein.

What is claimed is:
 1. A multi-functional surgical instrument, comprising: an elongate shaft extending between a proximal end and a distal end; a wrist extending from the distal end of the elongate shaft, wherein the wrist includes a distal clevis having a first curved surface, wherein the first curved surface defines at least one pivot axis; an end effector extending from the pivot axis of the wrist, the end effector comprising a first jaw and a second jaw, the first and second jaw being moveable between an open position in which ends of the first and second jaws are separated from each other and a closed position in which the ends of the first and second jaws are closer to each other as compared to the open position, wherein the end effector further includes a first outer pin and a first inner pin, wherein the first outer pin receives the first inner pin therein to movably connect the first and second jaws together, and wherein the first outer pin is received against the first curved surface such that the end effector is configured to pivot about the at least one pivot axis; and a tube extending through the elongate shaft and the wrist, the tube having an outlet in fluid communication with a nozzle cooperatively formed by an interior surface of the first and second jaws when the first and second jaws are in the closed position, wherein each of the first and second jaws are movable relative to the tube.
 2. The multi-functional surgical instrument of claim 1, wherein the wrist further comprises a proximal clevis, wherein the distal clevis forms in part a first joint about which the first and second jaw can rotate and the proximal clevis forms a second joint about which the wrist can pivot with respect to the elongate shaft.
 3. The multi-functional surgical instrument of claim 2, wherein the first joint is a different type of j oint from the second joint.
 4. The multi-functional surgical instrument of claim 1, wherein the ends of the first and second jaws define a portion of the nozzle therethrough, in the closed position.
 5. The multi-functional surgical instrument of claim 1, wherein the first jaw defines a hole in fluid communication with the nozzle.
 6. The multi-functional surgical instrument of claim 1, wherein the distal clevis has a second curved surface further defining the at least one pivot axis, wherein the end effector further includes a second outer pin and a second inner pin, wherein the second outer pin receives the second inner pin therein to movably connect the first and second jaws together, and wherein the second outer pin is received against the second curved surface such that the end effector is configured to pivot about the at least one pivot axis.
 7. The multi-functional surgical instrument of claim 6, wherein the first and second outer pins extend along the at least one pivot axis.
 8. The multi-functional surgical instrument of claim 7, wherein the first and second inner pins extend along the at least one pivot axis.
 9. The multi-functional surgical instrument of claim 8, wherein each of the first and second outer pins and each of the first and second inner pins are coaxial with the at least one pivot axis.
 10. The multi-functional surgical instrument of claim 1, wherein the first outer pin and the first inner pin extend along the at least one pivot axis.
 11. The multi-functional surgical instrument of claim 10, wherein each of the first outer pin and the first inner pin are coaxial with the at least one pivot axis.
 12. A surgical instrument, comprising: an elongate shaft extending between a proximal end and a distal end; a wrist extending from the distal end of the elongate shaft, the wrist comprising a distal clevis and a proximal clevis, the distal clevis comprising a plurality of distal arms each extending distally from a respective side portion of the distal clevis, wherein each distal arm comprises a distal recess formed by an upper distal surface of the respective distal arm and the distal recess is distally open to form a generally U-shape having an open portion; an end effector extending from the wrist, the end effector comprising a first jaw and a second jaw, and at least one pin joint formed between the first jaw and the second jaw, wherein the at least one pin joint is supported by the distal recess; and a cable segment extending along the wrist and attached to the end effector, wherein the cable segment is proximally drawn in tension to thereby maintain the at least one pin joint proximally against the distal recess.
 13. The surgical instrument of claim 12, wherein the at least one pin joint is formed by a first pin that extends from the first jaw into an opening in the second jaw.
 14. The surgical instrument of claim 12, wherein the first jaw and the second jaw rotate relative to each other about the pin joint.
 15. The surgical instrument of claim 14, wherein the pin joint collectively rotates relative to the distal recess.
 16. The surgical instrument of claim 12, wherein the first jaw and the second jaw are interlocked to form the at least one pin joint.
 17. The surgical instrument of claim 12, wherein the at least one pin joint includes a first outer pin and a first inner pin, wherein the first outer pin receives the first inner pin therein to movably connect the first and second jaws together, and wherein the first outer pin is received proximally against the distal recess.
 18. A surgical instrument, comprising: an elongate shaft extending between a proximal end and a distal end; a wrist extending from the distal end of the elongate shaft, the wrist including a distal clevis having a first curved surface, wherein the first curved surface defines a pivot axis; and an end effector extending from the wrist, including: a first jaw having a first outer pin and a first inner pin, wherein each of the first outer pin and the first pin extend along the pivot axis, a second jaw having a first inner pin and a second outer pin, wherein each of the second outer pin and the second inner pin pins extend along the pivot axis, a space between the first and second inner pins, wherein the first and second outer pins respectively receive the first and second inner pins therein to movably connect the first and second jaws together, and wherein the first outer pin is received against the first curved surface such that the end effector is configured to pivot about the pivot axis.
 19. The surgical instrument of claim 18, further comprising a tube extending through the elongate shaft and the space between the first and second inner pins, and wherein the end effector further includes an outlet in fluid communication with the tube. 